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CPGi # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT.AJC REFERRALIwo <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JOHN ROSS[ HAY CO <br /> C/O NAME GUARANTOR SSN <br /> JOHN ROSSI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> JOHN ROSSI HAY CO P.O. BOX 332 MANTECA CA 95336 209-823-3965 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 332 MANTECA CA 95336 209-823-3965 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INTI MONTHLY PAY AMTY <br /> 5977 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $315.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $31.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $821.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME <br /> EMPLOYER PHONE NO <br /> JOHN ROSSI HAY CO 209-823-3965 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AIRPORT WAY MANTECA CA 95336 <br /> SPOUSE CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JOHN ROSSI HAY CO 209-823-3965 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AIRPORT WAYM NT F} CA 95336 <br /> PREPARED BY CHECKED BY JDATE <br /> a r-le � , , <br />