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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL — <br /> ACCOUNT NO, DEPT.NO: REFERRAL <br /> 026p00.Q <br /> COPY <br /> LGUARANTOR FIRST _AST - MI TITLE LAST - AKA- FIRST Mf TITLE <br /> US TRUCK TRAILER REPAIR <br /> CIO NAMEGUARANTOR SSN <br /> QAMAR HUSSAIN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3833 DUCK CREEK DR STOCKTON CA 95215 <br /> 209-518-7839 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TBA STOCKTON CA 95210 209-942-3232 <br /> USER REFERENCE NO. - BILL FAT CYCLE STATUS DA.TEI BMC1 CBMC1 INTI MONTHLY PAY AMT PYMT I PROB <br /> pi IG DATE TERKA DATE <br /> 14438 HAZMAT 3120111 <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 /> CHARGE DEPT, NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> NQ <br /> 380 042000.0 2011 Hazmat Fee $285.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 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 /> US TRUCK TRAILER REPAIR 209-518-7839 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3833 DUCK CREEK DR STOCKTON CA 95215 <br /> SPOUSE. 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 /> US TRUCK TRAILER REPAIR 209-518-7839 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3833 DUCK CREEK DR TQC ON `� CA 95215 <br /> PREPARED BY CHECKED BY DATE COL. 20 13188) <br /> y <br />