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STATE OF CALIFORNIA EDMUND G.BROWN JR.,Governor <br /> DEPARTMENT OF INDUSTRIAL RELATIONS <br /> Division of Occupational Safety and Health e y�r` r ` r <br /> Modesto Distrix Office ,,••{`C C V <br /> 4206 Technology Drive,Suite 3 <br /> I& <br /> Modesto,CA 95356 <br /> Tel.#(209)545-7310 Fax#(209)545-7313 APR 09�■2015 <br /> EMPLOYER'S SIGNED STATEMENT OF ABATEMENT OF ENVIRONMEN I T AL- <br /> REGULATORYAND/OR GENERAL VIOLATIONS =cA �y�eoeor+nreh <br /> Pacific Car Wash & Marketplace, Inc. <br /> Pacific Ave <br /> Stocks El R1 COPY <br /> Stocktonn,,CA 95207 <br /> The law requires that violations observed during the inspection completed on 01/29/2015 of the place of <br /> employment located at 4405-4415 Pacific Ave, Stockton, CA be corrected within the time limit specified. Please <br /> notify the Division as soon as these conditions have been corrected by returning this completed form. Your <br /> response by completing, signing and mailing this form to the issuing office on or before the compliance date may <br /> avoid a follow-up inspection of your facilities. Failure to timely complete and return this form may result in <br /> issuance of a citation and civil penalty for violation of 8 CCR 340.4(c). <br /> NOTE: This form does not serve as a request for a time extension. If This signed statement or a summary <br /> there are serious problems beyond your control that prevent meeting shall be posted for three working <br /> a specified abatement date, contact the Division early,well within the days at or near each place the <br /> 15-day limit allowed for an appeal. regulatory and/or general violation(s) <br /> referred to in the citation occurred. <br /> PLEASE COMPLETE AND MAIL BY 03/20/15 <br /> LIST THE SPECIFIC MEASURES & EQUIPMENT TAKEN TO CORRECT EACH CITATION & ITEM NUMBER OF THE <br /> UNSAFE CONDITIONS AND DATE OF ABATEMENT. <br /> ❑ Continued on additional page <br /> All affected employees and their represent4WS have'been informed about abatement activities referenced in this <br /> document in conformance with 8 CCR Section 340.4(8). ❑ Yes ❑ No <br /> This certifies that all the unsafe conditions listed in the Division's citation dated UNKNOWN have now been <br /> corrected and all submitted abatement information is accurate. <br /> Signature: Date: <br /> Name: Title: <br /> OFFICE USE ONLY <br /> Compliance Safety and Health Officer: Date: <br /> District Manager: Date: <br /> [ ] Close/Comments <br /> RID: 0950624 Inspection Nr: 1021222 CSHO ID: G0994 Optional Report Nr: D43-15 <br /> Date mailed or delivered: 03/02/15 Ca1/051-A 160409/22/14) <br />