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CPG # TO: r vFICE OF REVENUE AND RECOVERY - <br /> �... ACCOUNT TRANSMITTALCopy <br /> ACCOUNT NO. DEPT. NO. REFERR <br /> MATC <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 ZIP CODE AREA PHONE NO. <br /> P.O. BOX 126 RIPON CA 95366 209-599-4187 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I ni PIP TP TPR <br /> 3174 HAZMAT 3/15/09 <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 DEFTNAIW DESCRIPTION , AMOUNT <br /> mn <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $30.00 1 ` <br /> State Surcharge Fee $24.00 <br /> Sm Hw Gen<5 Tons/yr $213.00 r <br /> Permit Fee Penalty $213.00 <br /> TOTAL $780.00 <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 ZIP CODE <br /> 24975 S AUSTIN RD RIPON CA 95366 <br /> SPOUSE CO—OWNER <br /> I. ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 1 <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 RIPON CA 1 95366 <br /> PREPARED BY CHECKED BY DATE �1 COL. 20(388) <br /> J <br />