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E <br />P kRTMENT OF INDUSTRIAL RELAT' IS <br />DTVISIOh OF OCCUPATIONAL SAFETY AND HEALTH - vALIOSHA <br />Cashier, Accounting Office <br />P.O. Box 420603 <br />San Francisco, CA 94142-0603 <br />Phone (415) 703-4291 or (415) 703A2915 FAX (415) 703-3037 <br />PENALTY REMITTANCE FORM <br />CIVIL PENALTY INFORMATION INSPECTION NUMBER 314995093 REPORTING ID 0950624 INDEX CODE 4024 <br />ESTABLISHMENT NAME Jazz Group. Inc. I Imperial Repair GTOUD. Inc. dba Imperial Truck Wash & Renai <br />CONTACT PERSON <br />PHONE NO. FAX NO. <br />SITE ADDRESS 2142 W. Yosemite. Manteca <br />MAILING ADDRESS 2142 W. Yosemite. Manteca. CA. 95337 <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 />-- -- -------- --FOR OFFICE USE ONLY ------------------------=----------------- <br />AUTHORIZATION <br />--------- — ---- — --- — — --- — * ------ — --- — — ----- <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/ddsti <br />Page 3 of 3 <br />