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CPG *# TO: OFFICE OF REVENUE AND RECOVERY Co p <br /> ��]ACCOUNT TRANSMITTAL V <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GOLDEN BAY FENCE PLUS IRON <br /> C/O NAME_ GUARANTOR SSN <br /> FLOYD CHAVEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> GOLDEN BAY FENCE PLUS IRON WORKS INC 4104 S B ST N/A STOCKTON CA 95206 209-944-9754 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4104 S B STREET STOCKTON CA 95206 209-944-9754 <br /> USER REFERENCE NO. I BILL TAT CYCLE STATUS DATE BMI CBM INT MONTHLY PAY AMT PDAT TPRRAQATP <br /> YMT P <br /> ROB <br /> 14547 HAZMAT <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 042000.0 2011 Hazmat Fee $270.00 380 042000.0 <br /> 230 042000.0 Hazmat Penalty Fee $27.00 380t042,000 <br /> 00.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 .0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380oo.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $346.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GOLDEN BAY FENCE PLUS IRON WORKS INC 209-944-9754 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4104 S B ST STOCKTON CA 95206 <br /> CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GOLDEN BAY FENCE PLUS IRON WORKS INC 209-944-9754 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4104 S B ST STOCKTON CA 95206 <br /> PREPARED BY ICHECKEDBY - 12ATE CJ $OI 1 1 COL. 20 (3M)) <br />