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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY ACCOUNT NO. REFERRAL <br /> DEPT. NO. <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> DOUBLE A TRUCK SVC(CLOSED) <br /> C/O NAME GUARANTOR SSN <br /> ANDREW SALMERON SR 11 <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> DOUBLE A TRUCK SVC (CLOSED) P.O. BOX 1402 DISCOVERY BAY CA 94505 209-467-0873 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2301 FIRWOOD CT DISCOVERY CA 94505 209-914-5653 <br /> USER REFERENCE NO. BILL kAT CYCLE STATUS DATE BMd CBMC INT MONTHLY PAY AMT PR <br /> 8084 HAZMAT 1.4/1 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO, DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $285.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $28.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen<5 TonS/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 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 /> TOTAL $788.50 <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 /> DOUBLE A TRUCK SVC (CLOSED) 209-467-0873 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1675 W CHARTER WAY#D STOCKTON CA 95206 <br /> CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME I EMPLOYER PHONE NO <br /> DOUBLE A TRUCK SVC(CLOSED) 209-467-0873 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1675 W CHARTER WAY S KTON CA 95206 <br /> REPARED BY CHECKED BY DATE �7i.�7_1 COL W (3M) <br />