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TO: OFFICE OF REVENUE AND RECOVERY. <br /> =, ACCOUNT TRANSMITTAL <br /> ACCOUNT N0. DEPT.N0." <br /> REFERRALCOPY <br /> 1 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST Ml TITLE <br /> DEBRUIN CONSTRUCTION INC <br /> CIO NAME GUARANTOR SSN <br /> RICHARD DEBRUIN <br /> MAILING STREET CITY ST. ZIP CODE AREA PHONE NO. <br /> DEBRUIN CONSTRUCTION INC P.O. BOX 1355 FRENCH CAMP CA 95231 209-462-5900 <br /> .RESIDENCE 'STREET CITY ST ZIP CODE AREA PHONE NO, <br /> PO BOX 1355 FRENCH CAMP CA 95231 209-462-5100 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> TERM D TP <br /> 14525 HAZMAT 3115112 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> ERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT,NO, DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $375.00 P89' I P43009.0"1 <br /> 30014290010 Hazmat Penalty Fee $37.50 P89L943002,01 <br /> p8q q429OOrO State Surcharge Fee $24.00 p8q <br /> 1 1 <br /> :p8q I 0 2 00 o I Electronic Surcharge $25,00 ' . p8q <br /> 1 1 <br /> 84 . Q 2 00 0 p8q <br /> 1 1 <br /> 8 0 2 000 1 289 -11 <br /> 8 0200. 8q 11 P43009.01 <br /> TOTAL. $461.50 <br /> GUARANTOR <br /> PRIOR STREET _ ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> :DEBRUIN CONSTRUCTION INC 209-462-5100 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1045 W CHARTER WAY STOCKTON CA 95206 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DEBRUIN CONSTRUCTION INC 209-462-5100 <br /> EMPLOYER STREETST 71P Conr <br /> 1045 W CHARTER WAY S OCKQN CA 95206 <br /> . . CHECKED BY IDATE Col. 20 (3188) <br />