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CPG # TO: r-VICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL .,.r copy ACCOUNT NO. DEPT. NO. REFERRAL <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 /> USER REFERENCE NO. ISILL bTAT ICYCLE ISTATUS DATEI BM CBMd INTI MONTHLY PAY AMT I PYMT PR <br /> 12560 HAZMAT 1.3/1,5/09 <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 DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 8 Chems @ $15.00 Each $120.00 <br /> 10% Late Charge $36.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $420.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST I 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 /> SJLGU&& 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 ,/7 pCOL. 20 13M) <br /> r d / <br />