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CPGw# 10: OCE OF REVENUE AND RECOVERY � • py TRANSMITTALACCOUNT NO. DEPT. NO. REFERRA �� <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CALIFORNIA STATE BLDG <br /> C/0 NAME GUARANTOR SSN <br /> CALIFORNIA STATE BLDG <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 31 E CHANNEL ST #108STOCKT0N CA 95202 209-948-7730 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 31 E CHANNEL ST#108 STOCKTON CA 95202 209-948-7730 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMI IN MONTHLY PAY AMT PYMT <br /> 6026 HAZMAT 1 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATIVE <br /> 4-4 <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> WA <br /> 230 042000.0 2012 Hazmat Fee $85.00 p8q <br /> 30 0142900 o Hazmat Penalty Fee $8.50 p8q 04 00 .0 <br /> �8q q42900,0 Sm Hw Gen <5 Tons/yr $213.00 p8q P43009.01 <br /> 8 0 2900,0 Permit Fee Penalty $213.00 p8q <br /> 80 1 0 2 90010 State Surcharge Fee $24.00 Bq 1 P43009.01 <br /> so 1 014290010 Electronic Surcharge Fee $25.00 p8q <br /> ao 1 0l42q00.ps a 00 .o <br /> TOTAL $568.50 <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> CALIFORNIA STATE BLDG 209-948-7730 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 31 E CHANNEL ST#108 STOCKTON CA 95202 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CALIFORNIA STATE BLDG 209-948-7730 <br /> EMPLOYER STREET MTY <br /> 31 E CHANNEL ST#108 TOCI�TON CA 95202 <br /> < CHECKED BY IDATE ,I COL. 20 (3/88) <br />