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E OF <br /> UE AND <br /> CPG # TO: �EIC <br /> ACCOUNT NTRANSMITTAL RY ... C O PID Y <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> D&M TRUCKING <br /> C/O NAME GUARANTOR SSN <br /> FRED COSTILLA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> D&M TRUCKING 3112 WALLACE AVE STOCKTON CA 95204 209-598-9410 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1612 E. ALPINE AVE STOCKTON CA 95205 209-598-9410 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT PYMT PR B <br /> 12943 HAZMAT 3/20/11 <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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2011 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D&M TRUCKING 209-598-9410 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1612 ALPINE RD STOCKTON CA 95205 <br /> SPOUSE- CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D&M TRUCKING 209-598-9410 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1612 ALPINE RD STOCKTO CA 95205 <br /> REPARED BY CHECKED BYDATE y— Co. zo p'm <br />