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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> V&W DRILLING INC <br /> C/O NAME GUARANTOR SSN <br /> ROBERT VICKERY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> V&W DRILLING INC 3806 DUCK CREEK DR STOCKTON CA 95215 209-469-7700 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 549 WALLACE CA 95254 209-329-7742 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBMI INT MONTHLY PAY AMT P M P B <br /> 14187 HAZMAT 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> F380 <br /> STOP MED REC NO CHARGE <br /> DEPT. NO. DESCRIPTION AMOUNT _CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 042000.0 2011 Hazmat Fee $285.00 <br /> 042000.0 State Surcharge Fee $24.00 <br /> 042000.0 Electronic Surcharge $25.00 <br /> 042000.0 Hazmat Penalty Fee $28.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> V&W DRILLING INC 209-469-7700 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 3806 DUCK CREEK DR STOCKTON CA 95215 <br /> SPOUS& CO—OWNER <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 /> V&W DRILLING INC 209-469-7700 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3806 DUCK CREEK D SJ KTON CA 95215 <br /> PREPARED BY - CHECKED BY _ L DATE ) / f/ COL. 20 (3M) <br /> / b <br />