Name:
E-mail:
Job title:
Firm name:
Address:
Inspection Address:
Optional report #:
Inspection date:
Issuance date:
Inspection #:
ITEM(S):
Requested extension date:
ITEM(S):
Requested extension date:

Why is an extension needed?

What are the measures being taken to ensure employees are not exposed to these hazards until these items are corrected?

Print the screen that displays after you hit submit!*


*This extension request must be posted as required by OAR 437-001-275(2)(j).