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CPG # TO: O' CE OF REVENUE AND RECOVERY COPY TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JOE'S AUTOMOTIVE OF LODI <br /> C/O NAME GUARANTOR SSN <br /> JOSE GOMEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 200 COMMERCE ST LODI CA 95240 209-367-9860 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 200 COMMERCE ST LODI CA 95240 209-367-9860 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd IN MONTHLY PAY AMT <br /> 14491 HAZMAT 1 . 3/1 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> 999 <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> fd <br /> 230 042000.0 2012 Hazmat Fee $115.00 8P43009.01 <br /> 30 014291010 Hazmat Penalty Fee $11.50R�8 <br /> P43009.01 <br /> 8 42 00 0 Sm Hw Gen <5 Tons/yr $213.00P44009.01 <br /> 8 0 2 00 0 Permit Penalty Fee $213.00P43009.01 <br /> So 0 2 00 0 State Surcharge Fee $24.00 4 009.01 <br /> 80 014290010 Electronic Surcharge Fee $25.00 q 1 P4 009.01 <br /> 80 11 0 2q()O.p p8q2q()0. 4 00 .0 <br /> TOTAL $601.50 <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JOE'S AUTOMOTIVE OF LODI 209-367-9860 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 200 COMMERCE ST LODI CA 95240 <br /> CG <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JOE'S AUTOMOTIVE OF LODI 209-367-9860 <br /> EMPLOYER STREET <br /> 200 COMMERCA 95240 <br /> - CHECKED BY IDATE <br />