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CPG # _ TO: OCE OF REVENUE AND RECOVERY ArroTIMT TRANSMITTALCOPY ACCOUNT NO. DEgNO. <br /> 02 <br /> LAST - GUARANTOR - FIRST LAST - AKA - FIRST MI TITLE <br /> COUNTRY CLUB FOOD& FUELC/O NAME ARANTOR SSN <br /> PHILLIP M ELDER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> COUNTRY CLUB FOOD& FUEL 1856 W COUNTRY CLUB BLVD STOCKTON CA 95205 209-662-0952 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4880 PEACH RD MANTECA CA 95337 209-662-0952 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 13814 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $85.00 p8q 4 00 .0 <br /> 30 042 900 0 Hazmat Penalty Fee $8.50 p8q 4 00 .0 <br /> 8 42 00 o I Sm Hw Gen <5 Tons/yr $213.00 Pq 4 00 .0 <br /> p8q 0 2 000 Permit Fee Penalty $213.00 p8q 4 00 .0 <br /> 80 0 2 000 State Surcharge Fee $24.00 P89 4 00 .0 <br /> 80 0 2 000 Electronic Surcharge Fee $25.00 p8q ------ - <br /> ?801 <br /> 00 080 0200. 8 400 .0 <br /> TOTAL $568.50 <br /> ZIP CODE <br /> PRIOR STREET <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> COUNTRY CLUB FOOD&FUEL 209-662-0952 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1856 COUNTRY CLUB BLVD STOCKTON CA 95204 <br /> ST FIRST MI TITLE SOC SEtEMPLOIER <br /> fPHONE <br /> DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME <br /> COUNTRY CLUB FOOD &FUEL 209-662-0952 <br /> EMPLOYER STREET <br /> 1856 COUNTRY C UB BLVD SyOCKTON CA 95204 <br /> /�� CHECKED BY DATE .I COL 20 (3180) <br />