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CPG # TO: C CE OF REVENUE AND RECOVERY TRANSMITTAL COPY ACCOUNT NO. DEPT.NO. REFER 026000.0 RAL LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE OFF ROAD ENTERPRISES C/O NAME GUARANTOR SSN WADE MARTIN MAILING STREET CITY ST ZIP CODE AREA PHONE NO, 2953 CHERRYLAND AVE #BSTOCKTON CA 95215-2233 209-931-1170 RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. 3261 CHERRYLAND AVE. STOCKTON CA 95215 (209)969-7178 USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd C13MI IINJ MONTHLY PAY AMT 6985 HAZMAT 3/15/12 LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE SERVICE DATE: DATE OF TART STOP MED REC NO CHARGE CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT NR 230 042000.0 2012 Hazmat Fee $285.00 p8q P43009-01 30 1 042 00 0 Hazmat Penalty Fee $28.50 p8q Da 00 .0 p8q I q429OOrO I Sm Hw Gen <5 Tons/yr $213.00 8q 1 P43009.01 �8q I 0 2 00 0 I Permit Fee Penalty $213.00 p8q P43009-01 80 1 0 2 00 0 State Surcharge Fee $24.00 8q P4300P.01 80 2 00 0 I Electronic Surcharge Fee $25.00 1 p8qa 00 .0 ?801 O�2qOO.p 043009.01 TOTAL $788.50 PRIOR STREET rITY ST ZIP CODE I EMPLOYER NAME EMPLOYER PHONE NO OFF ROAD ENTERPRISES 209-931-1170 EMPLOYER STREET CITY ST ZIP CODE 2953 CHERRYLAND AVE#B STOCKTON CA 95215-2233 ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO I I I EMPLOYER NAME EMPLOYER PHONE NO OFF ROAD ENTERPRISES 209-931-1170 EMPLOYER STREET CITY 2953 CHERRYLAND VFX B T CKTON CA 95215-2233 CHECKED BY JDATE .I COL. 20 (3188)