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CPG'#4,i\= TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRALC;Opy <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLELAST - AKA FIRST MI 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 209-462-5100 <br /> r <br /> RESIDENCE STREET `r 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 6mC1 CBMC1 INT MONTHLY PAY AMT PYMT PRO <br /> 14525 HAZMAT <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 Nn DEPT, NO, DESCRIPTION AMOUNT Kin CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2007 - 2011 Hazmat Fee $1875.00 380 042000.0 <br /> L -j230 042000.0 Hazmat Penalty Fee $187.50 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $2111.50 <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 /> DEBRUIN CONSTRUCTION INC 209-462-5100 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1045 W CHARTER WAY STOCKTON CA 95206 <br /> CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 1 I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DEBRUIN CONSTRUCTION INC 209-462-5100 <br /> t <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1045 W CHARTER WAY STO TON CA 95206 <br /> PREPARE D BY I CHECKED BY DATE �/jCl/I, coy za Isael <br />