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CPG # TO: nFFICE OF REVENUE AND RECOVERY ACCOUNT TRANSMITTALACCOUNT NO. DEPT. NO. REFERRAL COPY <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> A&D RUBBER PRODUCTS CO INC <br /> C/O NAME GUARANTOR SSN <br /> A&D RUBBER PRODUCTS CO INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> A&D RUBBER PRODUCTS CO INC 1438 BOURBON ST STOCKTON CA 95204 209-992-1100 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1438 BOURBON ST STOCKTON CA 95204 209-941-0100 <br /> P <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> T PR <br /> 12560 HAZMAT 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST Al TITLE RECIPIENTUSER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2011 Hazmat Fee $330.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $33.00 <br /> TOTAL $412.00 <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 /> A&D RUBBER PRODUCTS CO INC 209-992-1100 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1438 BOURBON ST STOCKTON CA 95204 <br /> S-POUS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A&D RUBBER PRODUCTS CO INC 209-992-1100 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1438 BOURBON ST STOCKTON CA 95204 <br /> REPARED BY, CHECKED BY DATE J Z s cOL. xo t3rea1 <br />