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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL /� O(��J <br /> ACCOUNT NO. DEPT. NO. REFERRAL ,! f\\\/,J'_ '111lllJJJ111--� U <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> C DEJONG TRUCKING INC <br /> C/O NAME GUARANTOR SSN <br /> DEJONG TRUCKING <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> C DEJONG TRUCKING INC P.O. BOX 126 RIPON CA 95366 209-599-4187 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO. <br /> P.O. BOX 126 RIPON CA 95366 209-599-4187 <br /> USER REFERENCE NO. BILL TAT ICYCLE I STATUS DATE BMd CBMd INTI MONTHLY PAY AMT I PYMT PROB <br /> 3174 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 AMOUNTCH� 7 DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5 Tons/yr $213.00 IRI, PIP 7 <br /> 2010 Hazmat Fee $300.00 <br /> State Surcharge Fee $24.00 / <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $30.00 <br /> Ast Fac 1 Ok-<=100 K Gal $337.00 IL <br /> Payment -$580.18 <br /> i; TOTAL $348.82 <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 /> C DEJONG TRUCKING INC 209-599-4187 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 24975 S AUSTIN RD RIPON CA 95366 <br /> SPOUSE CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> C DEJONG TRUCKING INC 209-599-4187 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 24975 S AUSTIN RD RIPO CA 95366 <br /> REPARED BY CHECKED BY DATE - O /D COL. 20 (388) <br />