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CPG # TO: r- ICE OF REVENUE AND RECOVERY <br /> ti„ ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL �'LIVrJ V <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 CBMINT MONTHLY PAY AMT T PR B <br /> nATP <br /> 12943 HAZMAT 1.11/,151091 <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 2005 - 2009 Hmmp <br /> Annual Fee $350.00 <br /> 1 Chem @ $15.00 <br /> Each Year $75.00 <br /> 10% Late Charge $42.50 <br /> TOTAL $467.50 <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 /> S-POUS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <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 STOC TO CA 95205 <br /> REPARED BY CHECKED BY - DATE C Co <br />