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STATE OF CALIFORNIA _ _ ! DIyIUND G.BROWN JR.,Governor DEPARTMENT OF INDUSTRIAL RELATIONS Division of Occupational Safety and Health - - - Modesto District Office APR 0 9 2015 4206 Technology Drive,Suite 3 Modesto,CA 95356 I Tel.9(209)5457310 Fax p(209)545-7313 ENVIRONMENTAL. 1!rft un aciPriTil,1rkIT EMPLOYER'S SIGNED STATEMENT OF ABATEMENT OF SERIOUS VIOLATIONS Pacific Car Wash& Marketplace, Inc. 4405-4415 Pacific Ave Stockton,CA 95207 El FOIE COPY The law requires that violations observed during the inspection completed on 01/29/2015 of the place of employment located at 4405-4415 Pacific Ave, Stockton, CA be abated (corrected).within the time limit specified. Labor Code 6320(b) requires that you submit this signed statement under penalty of perjury that you have complied with the abatement terms. You are eligible for a 50% reduction of the civil penalty assessed for this serious violation pursuant to Labor Code 6319(8). However, the Division shall not grant such a reduction unless it receives an "EMPLOYER'S SIGNED STATEMENT OF ABATEMENT OF SERIOUS VIOLATIONS" together with sufficient supporting evidence acceptable to the Division, if necessary to prove abatement, within 10 working days after the end of the abatement period—regardless of whether you appeal the serious citations. If there are problems beyond your control that prevent you from meeting the abatement date,contact the Division as soon as possible so that a request for extension can be considered. This signed statement shall be posted I THIS FORM MUST BE RECEIVED AT THE ABOVE ADDRESS ON OR BEFORE for three (3)working days at or near 03/13/15 each place the serious violation referred to in the citation occurred. In a separate attachment, please list and describe the specific measures taken and equipment used to abate each serious violation,and also attach supporting evidence: • For each citation, provide the citation number, number of instances, abatement date, and a description of the specific measures taken to abate the serious citation. • List the evidence attached to this form proving that the measures were taken and the violations were fully abated. Examples of suitable evidence include, but are not limited to, photographs and copies of attendance sign- in sheets,written procedures,and receipts for payment of services or equipment. ❑ Evidence is attached r r;i All affected employees and their representatives,f ave beeh,infgrmgd;about abatement activities referenced in this document in conformance with 8CCR Section 340.4(g). ❑ Yes ❑ No _ I have reviewed the foregoing statement and declare under penalty of perjury that it is true and correct to the best of my knowledge and all submitted abatement information is accurate. Executed at , California by Signature: Date: Name: Title: _ OFFICE USE ONLY Compliance Safety and Health Officer: _ Date: District Manager: Date: [ ]Close/Comments RID: 0950624 Inspection Nr: 1021222 CSHO ID: G0994 Optional Report Nr: 043-15 Date mailed or delivered: 03 02 15 Cal/OSHA 161(2/20/15)