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CPG' # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL c <br /> Fly <br /> ACCOUNT NO. DEPT. ft REFERRAL0 <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SPECIALIZED TRUCK SVC <br /> C/O NAME GUARANTOR SSN <br /> DAVID RAY <br /> MAILING STREET CITY ST ZIPCODE AREA PHONE NO. <br /> 3665 E CHEROKEE RD STOCKTON CA 95205 209-462-5078 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-462-5078 <br /> USER REFERENCE NO. BILL kAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I ni <br /> PYMT P B <br /> 8684 HAZMAT 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 <5tons/yr $213.00 <br /> 2010 Hazmat Fee $300.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $30.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $805.00 <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 /> SPECIALIZED TRUCK SVC 209-462-5078 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3665 E CHEROKEE RD STOCKTON CA 95205 <br /> S-POUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I 1 I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SPECIALIZED TRUCK SVC 209-462-5078 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3665 E CHEROK E RD STOCK N CA 95205 <br /> REPARED B - CHECKED BY +�� DATE ,� r�w coL. 20 (sree) <br />