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CPG`# TO: OFFICE OF REVENUE AND;RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> i <br /> ACCOUNT NO. DEPT. NO. REFERRAL li I <br /> i <br /> 026000.0 <br /> I i <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST NII TITLE <br /> D.H. WINN TRUCKING <br /> CIO NAME GUARANTOR SSN <br /> RUSSELL D WINN i <br /> MAILING STREET CITY, ST ''ZIP CODE AREA PHONE NO. <br /> D.H..WINN TRUCKING.P.O. BOX 400 LOCKEFORD CA 95237 209-727-5608 <br /> i <br /> RESIDENCE STREET CITY ST 'ZIP CODE AREA PHONE NO. . <br /> RUSSELL WINN/14711 E.JUNIPER AVE LOCKEFORD CA 95237 209-727-5608 <br /> } <br /> PYMT I <br /> USER REFERENCE NO. BILL 3TAT CYCLE STATUS DAM PROB:: <br /> TE BCBM INT MONTHLY PAY AMT <br /> 13264 HAZMAT 3120110 f <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 /> I <br /> I <br /> CHARGE DEPT.'NO. DESCRIPTION AMOUNT CHARGE, DEPT. NO. DESCRIPTION AMOUNT <br /> 230' 026000.0 Sm H Gen<5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $330-00 - <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Ast Fac 1 Ok/=100 K Gal $337.00- <br /> I <br /> Haz Mat Penalty Fee $33.00 <br /> Permit Fee Penalty $550.00 <br /> TOTAL $1512.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO UC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D.H. WINN TRUCKING 209-727-5608 <br /> EMPLOYER STREET CITY ' ST ZIP CODE <br /> 12505 E BRANDT RD LOCKEFORD CA 95237 <br /> SL20USFr 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 /> D.H. WINN TRUCKING 209-727-5608 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 12505 E BRANDT RD LOG E , D CA 95237 <br /> PREPARED BY CHECKED BY DATES�J coL �o Iarea) <br /> 3i' i <br />