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CPG # _ TO: OFFICE OF REVENUE AND RECOVERY <br /> ' tj ACCOUNT TRANSMITTAL <br /> � opy <br /> ;~ REFERRAL <br /> ACCOUNT NO. DEPT. NO. <br /> 026000.0 <br /> LAST-- GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE y <br /> D.H. WINN TRUCKING <br /> CIO NAME GUARANTOR SSN � <br /> RUSSELL D WINN i3 <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 /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE.NO. <br /> RUSSELL WINN/14711 E. JUNIPER AVE LOCKEFORD CA 95237 209-727-5608 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS RATE BM CBM lNT MONTHLY PAY AMT PYMIp T PK B <br /> 13264 HAZMAT 3115109 i <br /> CHARGES I <br /> LAST RECIPIENT FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <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 /> 6 Chems @ $15.00 Each $90.00 <br /> 10% Late Charge $33.00 s <br /> State Surcharge Fee $24.00 t I I I I 1 ' <br /> Sm Hw Gen<5tons/yr $213.00 <br /> I <br /> Permit Fee Penalty $213.00- <br /> TOTAL $813.00 <br /> GUARANTOR a <br /> DOB DR LIC NO TO LIC NO <br /> J <br /> PRIOR STREET CITY ST ZIP CODE <br /> f <br /> i <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 /> SQ CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO-LIC NO <br /> - 31 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D.H. WINN TRUCKING 209-727-5608 <br /> _ k <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 12505 E BRANDT RD LOCKEFORD CA 95237 <br /> PREPARED BYCHECKED-BY DATE COL. 20(3188) <br />