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TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL � (: 01D 1MACCOUNT NO. DEPT.NO. REFERRAL lu( <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CV FABRICATORS INC <br /> C/O NAME GUARANTOR SSN <br /> CV FABRICATORS INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 17547 COMCONEX RD MANTECA CA 95336 209-239-7500 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-239-7500 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INd MONTHLY PAY AMTR04 DATE- <br /> 13353 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DATE:SERVICE DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NA dn <br /> 230 042000.0 2012 Hazmat Fee $345.00 8044009.01 <br /> 30 014290010 Hazmat Penalty Fee $34.50 P89104300P.01 <br /> p8q q42900rO State Surcharge Fee $24.00 p8q <br /> �8q 0I42q00,0 Electronic Surcharge Fee $25.00 8q 1 P43009.01 <br /> BO I 0 2 00 0 I p8q4 00 .0 <br /> 80 1 0I42q0010 I 38q <br /> 80 0 2 00.p I �Bq 1, P43009.0, <br /> TOTAL $428.50 <br /> GUARANTOR <br /> PRIOR STREET CITY qT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CV FABRICATORS INC 209-239-7500 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 17547 COMCONEX RD MANTECA CA 95336 <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CV FABRICATORS INC 209-239-7500 <br /> EMPLOYER STREET rITY ST 71P rOnF <br /> 17547 COMCONEX RD N CA 95336 <br /> f CHECKED BY IDATE COL. 10 (3/88) <br />