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CPG # TO: OF^T.CE OF REVENUE AND RECOVERY <br /> TRANSMITTAL c <br /> • u LJU <br /> ACCOUNT NO. DEPT. N0. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SUPER SMOG&REPAIR <br /> C/O NAME GUARANTOR SSN <br /> ROBERT VASQUEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 511 N AMERICAN ST STOCKTON CA 95202 916-261-5094 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 849 SHELLWOOD WAY SACRAMENTO CA 95831 916-261-5094 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM C11 ,11 1111 MONTHLY PAY AMT <br /> 13397HAZMAT 3/15/12 <br /> W9 k <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT 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 /> WA <br /> 230 042000.0 2012 Hazmat Fee $100.00 8q 1 P43009.11 <br /> 30 1 014290010 1 Hazmat Penalty Fee $10.00 p8q1043009.01 <br /> p8q q429OOrO Sm Hw Gen <5 Tons/yr $213.00 p8q 1 P43009-01 <br /> p8q 0 2 00,0 Permit Fee Penalty $213.00 8P43009.01 <br /> 80 0 2 00 0 State Surcharge Fee $24.00 8q 1 P43009-0 <br /> 80 0142 0010 1 Electronic Surcharge Fee $25.00 8 4 00 .0 <br /> 8 0200 8q P43009.01 <br /> TOTAL $585.00 <br /> PRIOR STREET qTZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SUPER SMOG & REPAIR 916-261-5094 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AMERICAN ST STOCKTON CA 95202 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SUPER SMOG &REPAIR 916-261-5094 <br /> EMPLOYER STREET rjTY ;T 71P rnnF <br /> 511 N AMERICAN S (�CKT N CA 95202 <br /> CHECKED BY JDATE ,I COL. 20 (3188) <br />