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DEPARTMENT OF INDUSTRIAL RELATIONS <br /> DIVISION OF OCCUPATIONAL SAFETY AND HEALTH- CAL/OSHA <br /> Cashier, Accounting Office <br /> P.O. Box 420603 <br /> San Francisco, CA 94142-0603 <br /> Phone (415) 703-4291 or (415)7034295 FAX (415)703-3037 <br /> PENALTY REMITTANCE FORM <br /> CIVIL PENALTY INFORMATION INSPECTION NUMBER 316703578 REPORTING ID 0950624 INDEX ODE 4024 <br /> ESTABLISHMENT NAME Arthur L. Hunot dba Hunot Retardant Company <br /> t <br /> CONTACT PERSON <br /> PHONE NO. FAX NO. <br /> SITE ADDRESS 1950 Sikorsky Way, Stockton <br /> MAILING ADDRESS PO Box 478, Goleta, CA, 93116 <br /> CITATION INFORMATION (Penalties are due within 15 working days of receipt of this notification unless contested. If you are appealing any <br /> item of this citation, remittance is still due on all items that are not appealed.) <br /> Payment is for the following Citation Items: (e.g. Citation 1, Items 1-5; Citation 3) <br /> TYPE OF PAYMENT ENCLOSED <br /> CHECK OR MONEY ORDER INFORMATION <br /> CHECK ENCLOSED IN THE AMOUNT OF $ <br /> MONEY ORDER ENCLOSED IN THE AMOUNT OF $ <br /> (Please make check or money order payable to CAL/OSHA and mail to the Cashier, Accounting Office, at the above address. Reference the <br /> Inspection Number on the "memo" portion of your check or money order.) <br /> Go to www.dir.ca.gov/dosh to access the on-line third party secure payment processing site <br /> OR Complete this section and fax to (415)703-3037 <br /> CREDIT CARD INFORMATION: CONVENIENCE FEE APPLIES <br /> MASTERCARD CREDIT CARD NO. EXPIRATION DATE <br /> CREDIT CARD SECURITY CODE(last 3 digits on back of card) <br /> NAME OF CARDHOLDER SIGNATURE <br /> CARDHOLDER PHONE NO. FAX NO. <br /> AMOUNT OF PAYMENT $ <br /> -------------------------------------- <br /> ------------ FOR OFFICE USE ONLY -------------------------------------------------- <br /> AUTHORIZATION NO. DATE PROCESSED <br /> PROCESSED BY <br /> Please call (415) 703-4291 or 703-4295 or complete the information above and fax to (415) 703-3037 <br /> ELECTRONIC FUNDS TRANSFER EFT OPTION: NO CONVENIENCE FEE APPLIES: GO TO www.dir.ca.gov/dosh <br /> al/ SHA P <br /> Page 2 of 2 <br />