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CP # TO: OFFICE REVENUE AND RECOVERY ,-CFly� <br /> ACCOUNT TRANSMITTAL <br /> (a <br /> ACCOUNT NO. DEPT. P REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ELEGANT SURFACES <br /> C/O NAME GUARANTOR SSN <br /> JOHN POLIMENO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ELEGANT SURFACES 551 CARNEGIE ST MANTECA CA 95337 530-681-2349 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONENO. <br /> P.O. BOX 705 BYRON CA 94514 209-456-0443 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I PYMT <br /> 8165 HAZMAT 1.3/20/1.0 <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 CHARGE E DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $315.00 <br /> State Surcharge Fee $24.00 J/ <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $31.50 <br /> Permit Fee Penalty $213.00 p= <br /> TOTAL $821.50 <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 /> ELEGANT SURFACES 530-681-2349 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 551 CARNEGIE ST MANTECA CA 95337 <br /> SiPAUSP} CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 1 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ELEGANT SURFACES 530-681-2349 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 551 CARNEGIE TMA T CA 95337 <br /> REPAREDB � CHECKED BV DATE _��T -�d COL. 2o (aiee) <br />