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CPG # TO: O' .�E OF REVENUE AND RECOVERY 3kr'rnTMrri TRANSMITTAL ACCOUNT NO. DEPT.No. COPY REFERRAL 026000.0 LAST - GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE MIRACLE MILE DRY CLEANERS C/O NAME GUARANTOR SSN WILTON FAMILY LLC MAILING STREET CITY ST ZIP CODE AREA PHONE NO. MIRACLE MILE DRY CLEANERS P.O. BOX 692163 STOCKTON CA 95269-2163 209-464-0411 RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. P.O. BOX 692163 STOCKTON CA 95269-2163 209-481-2414 USER REFERENCE NO. I BILL kTAT ICYCLE ISTATUS DATEI BM d CBM d INMONTHLY PAY AMT n,'=ynMA'TP PHL) . nAZF- 6115 HAZMAT 3/15/12 '--N— LAST - RECIPIENT FIRST MI TITLE ECIPIENT USER REFERENCE NO/NARRATIVE SERVICE DATE: DATE OF START STOP MED REC NO CHARGE CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGEI DEPT.NO. DESCRIPTION AMOUNT PjA .1 1 230 042000.0 2012 Hazmat Fee $255.00 8 4 009.01 1 ?30J 1 014290011 1 Hazmat Penalty Fee $25.50 P89 04300P.0 1 1 p8q I q42900r0 Sm Hw Gen <5 Tons/yr $213.00 p8q P4;009.01 1 p8q 0,42Q00,0 Permit Fee Penalty $213.00 p8q 1 P43009.01 1 ?8q 0I42q0010 State Surcharge Fee $24.00 1 p8q 1 P43009.0, ?81) 1 0I42q0010 Electronic Surcharge Fee $25.00 p8q 1 P43009.01 1 ?801 1 002400-P 1 p8q 1 P43009.01 1 TOTAL $755.50 DOR DR I Ir,NO Al]TO I ICNO PRIOR STREET rlTy ZIP CODE EMPLOYER NAME EMPLOYER PHONE NOI MIRACLE MILE DRY CLEANERS 209-464-0411 EMPLOYER STREET CITY ST r---ZIP cop 82 W CASTLE ST STOCKTON CA 1 95204 AST FIRST MI TITLEI SOC SEC NO. DOB I DR LIC NO AUTO LIC NO EMPLOYER NAME EMPLOYER PHONE NO MIRACLE MILE DRY CLEANERS 209-464-0411 EMPLOYER STREET CITY -OnF IP 82 W CASTLE ST T C O CA 95204 PRFPARFn RY CHECKED BY IDATE COL. 20(3M)