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r <br /> f CPG # f -'TO: �ICE OF REVENUE AND RECOVERY <br /> 4 ACCOUNT' TRANSMITTAL <br /> ACCOUNT NO. REFERRAL Q <br /> DEPT'. NO. <br /> 026000.0 C (oy <br /> LAST - GUARANTOR - FIRST MI TITLE LAST. - AKA FIRST MI TITLE <br /> SAM FREITAS TRUCKING INC <br /> C/O NAME GUARANTOR SSN <br /> —SAM FREITAS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2420 E EIGHT MILE RD STOCKTON CA 95210 209-474-0294 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2420 E EIGHT MILE ROAD STOCKTON CA 95210 209-474-0294 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTH!LY PAY AMT PY T PROB <br /> 9741 HAZMAT t if ILAI I 1 11 1 L, 1 3115109 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <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 025000.0 2009 Hmmp Annual Fee $240.00 <br /> 8 Chems @ $15.00 Each $120.00 <br /> 10% Late Charge $36.00 <br /> State Service Fee $24.00 <br /> Sm Hw Gen¢5 Tons/yr $213:00 r <br /> Permit Fee Penalty $213.00 <br /> TOTAL $846.00 <br /> GUARANTOR <br /> DOS DR LIC NO AUTO LIC NO I <br /> PRIOR STREET CITY I ST- .j ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAM FREITAS TRUCKING INC 209-474-0294 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2420 E EIGHT MILE RD STOCKTON CA 95210 <br /> 94LOWS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LEC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAM FREITAS TRUCKING INC 209-474-0294 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2420 E EIGHT MILE RD STOCKTON CA 1 95210 <br /> REPARED BY 4 1 CHECKED BY ATE / COQ 20(area) <br /> 6 0 <br />