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DEPARTMENT OF INDUSTRIAL <br /> DIVISION OF OCCUPATIONAL SAFETY AND HEALTHNSCAL/OSHA RECEIVE[,! <br /> Accounting Office-Cashiering Unit <br /> P.O. Box 420603 APR 09 2015 <br /> San Francisco,CA 94142-0603 <br /> Phone(415)703-4291 or(415)703-4308 Fax(415)703-3037 ENVIRONMENTAL. <br /> f4CA11,j"CojoriArAl, <br /> Please mail or far this form back to the above address to properly credit your po ment <br /> PENALTY REMITTANCE FORM <br /> CIVIL PENALTY INFO INSPECTION NO.: 1 1021222 _ REPORTING ID: 0950624 <br /> ESTABLISHMENT NAME: Pacific Car Wash&Marketplace, Inc. FEIN/SEIN: UNKNOWN <br /> CONTACT PERSON: UNKNOWN UNKNOWN <br /> PHONE NO.: UNKNOWN I FAX NO.: UNKNOWN <br /> SITE ADDRESS: 4405-4415 Pacific Ave,Stockton,CA 95207 <br /> MAILING ADDRESS: 4405-4415 Pacific Ave,Stockton,CA 95207 <br /> CITATION INFORMATION: Penalties are due within 15 working days of receipt of this notification unless contested. If <br /> you are appealing any item of this Citation, remittance is still due on all items that are not appealed. <br /> PAYMENT INSTRUCTIONS: <br /> • Put a"✓" next to the Citation(s)that you are paying. <br /> • Write the amount paid in the"AMOUNT PAID"column. <br /> • Please indicate the"TOTAL AMOUNT PAID". <br /> ✓ SUMMARY OF PENALTIES PAID AMOUNT PAID <br /> Citation 1 Item 1,General $ <br /> Citation 1 Item 2,General $ <br /> Citation 1 Item 3, General $ <br /> Citation 1 Item 4,General 2 $ <br /> Citation 2 Item 1,Serious $ <br /> Citation 3 Item 1,Serious $ <br /> TOTAL AMOUNT PAID $ <br /> TYPE OF PAYMENT ENCLOSED <br /> Fill In the check,a-check reference,or money order Information below: <br /> CHECK# ENCLOSED IN THE AMOUNT OF: $ <br /> E-CHECK REFERENCE# PAID IN THE AMOUNT OF: $ <br /> MONEY ORDER# ENCLOSED IN THE AMOUNT OF: $ <br /> Please make check or money order payable to Department of Industrial Relations - Cal/OSHA and mail to the Cashier, <br /> Accounting Office,at the above address. Reference the Inspection Number on the"memo" portion of your check or money <br /> order. Note: For your convenience, the 7Departmeh.tMdf4*lodustrial Relations accepts electronic payments at <br /> See pages 1 through 4 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. <br /> Citation and Notification of Penalty Page 13 Of 14 Col/OSHA-2 Rev 12/2014 <br />