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CPG"# TO: OFFICE OF REVENUE AND RECOVERY <br /> jft ACCOUNT TRANSMITTAL • COPY <br /> ti REFERRAL <br /> ACCOUNT NO. DEPT. NO, <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TONY'S AUTO SERVICE <br /> C/O NAME GUARANTOR SSN <br /> JOE M FRANCO <br /> il <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1951 S EL DORADO ST STOCKTON CA 95206 209-688-2255 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1951 S EL DORADO ST STOCKTON CA 95206 209-688-2255 <br /> FHU <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBM INT MONTHLY PAY AMT P <br /> 5505 HAZMAT 1.3/20/10 <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 /> CHARGEKin DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <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 /> TONY'S AUTO SERVICE 209-688-2255 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1951 S EL DORADO ST STOCKTON CA 95206 <br /> S?685& CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TONY'S AUTO SERVICE 209-688-2255 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1951 S EL DORADO ST OC ON CA 95206 <br /> REPARED BY CHECKED BY DATE /�� {�� coL. za (3M)) <br />