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CPC^ # TO: OFFICE OF REVENUE AND RECOVERY 0 <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. f� REFERRAL �� py <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> THANH AUTO REPAIR 1 11 11 j 11 11 <br /> C/O NAME GUARANTOR SSN <br /> MARK HA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1402 BOURBON ST STOCKTON CA 95204 209-943-6322 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5504 RAYANNA DR STOCKTON CA 95212 209-478-2438 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMC1 CBM INT MONTHLY PAY AMT PYMT PROB <br /> 13887 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $115.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 an <br /> Hazmat Penalty Fee $11.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $601.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST I ZIP CODE <br /> EMPLOYER NAME <br /> EMPLOYER PHONE NO <br /> THANH AUTO REPAIR 209-943-6322 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1402 BOURBON ST STOCKTON CA 95204 <br /> SPAU&& CO-OWNER <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 /> THANH AUTO REPAIR 209-943-6322 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1402 BOURBON ST ST CK CA 95204 <br /> REPARED BY CHECKED BY DATE -� 5--/O COL. 20 (3M) <br />