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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • COPY <br /> WE <br /> DEPT. NO. REFERRAL <br /> 026000.0 <br /> R - FIRST MI TITLE LAST - AKA - FIRST Mt TITLE <br /> E SECURITY <br /> GUARANTOR SSN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> AD FORCE PRIVATE SECURITY P.O. BOX 55331 STOCKTON CA 95205 209-465-8420 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-465-8420 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMC1 CUM C INT MONTHLY PAY AMTPYMT PROB <br /> 8665 HAZMAT 3/20/11 <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 /> CHKin ARGE I 1W <br /> DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPTAL. CRIPTION )AMOUNT <br /> 230 026000.0 2011 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AD FORCE PRIVATE SECURITY 209-465-8420 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3108 CHERRYLAND AVE STOCKTON CA 95215 <br /> SP0499 CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AD FORCE PRIVATE SECURITY 209-465-8420 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3108 CED <br /> AVE STOC TON CA 95215 <br /> REPARED BY CHECKED BY DATE �✓ds-)�� coL. 20 13/88) <br />