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ACCOUNT Np r1(:E op <br /> ACCO <br /> 2, T E AND RECD yERy <br /> DEPT, NOtt <br /> . REFERRAL ANSMZTTAz, _ <br /> LAST - 026000.0 O <br /> GUARANTOR - FIRST <br /> FARIgg AUTO REPAIR MI TITLE <br /> C/O NAME LAST - AKA <br /> JOSE F - FIRST <br /> ARIAS GUARANTOR SSN MI TITLE <br /> MAILING STREET <br /> 2029E CHEROKEE RD STOCKTON CA 95205 CITY <br /> ST ZIP CODE <br /> AREA PHONE NO, <br /> RESIDENCE <br /> STREET <br /> CIT� 209-29-3370 <br /> 1823 CHEROKEE ROAD SPC.OI ST STOGKTOKTON ZIP CODE AREA PHONE NO. <br /> CA 95205 209-570-2081 <br /> USER REFERENCE NO. BILL TA7 CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> PVM P B <br /> 10513 HAZMAT <br /> 3/20/10 <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 DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $100.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $10.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $585.00 <br /> GUARANTOR <br /> DOB 11 DR LIC NO AUTO LIC NO <br /> PRIOR STREET =209-29-3370 <br /> DE <br /> I <br /> EMPLOYER NAME <br /> FARIAS AUTO REPAIR EMPLOYER STREET ODE2029 E CHEROKEE RD STOCKTON <br /> SpQWS . CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 1 I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FARIAS AUTO REPAIR 209-29-3370 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2029 E CHEROKS Op N CA 95205 <br /> CHECKED BY DATE o`f5'-/ COL. 20 (3W <br /> REPARED BY a� <br />