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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> Ltj ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> r 026000.0 copy <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> US TRUCK TRAILER REPAIR <br /> I C/O NAME <br /> GUARANTOR 58N <br /> QAMAR HUSSAIN <br /> MAILING STREET CITY ST ZIP CODE <br /> AREA PHONE NO. <br /> 3833 DUCK CREEK DR STOCKTON CA 95215 209-518-7839 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-942-3232 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT ROB <br /> 14438 HAZ MAT <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 /> CHARGEKJn DEPT. NO. DESCRIPTION AMOUNT CHARGE ' DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 & 2010 Hazmat Fee $570.00 <br /> Hazmat Penalty Fee $57.00 <br /> TOTAL $627.00 <br /> GUARANTOR <br /> DOB DR LEC NO AUTO LIG 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 /> &fly CO--OWNER <br /> I.AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LfC 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 ST C CA 95215 <br /> PREPARED BY CHECKED BY jDATE COL zo (3M) <br /> i <br /> 1 <br />