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CPG # TO: ^FFICE OF REVENUE AND RECOVERY —cO py <br /> ACCOUNT TRANSMITTAL '' V <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CANELO'S MARKET <br /> C/O NAME GUARANTOR SSN <br /> FELIPE SERNA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2031 S EL DORADO ST STOCKTON CA 95206-2733 209-981-2538 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4702 MOSSBROOK LN STOCKTON CA 95206 209.981-2538 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE Bm <br /> CBMcl INT MONTHLY PAY AMT YM <br /> 14595 HAZMAT I I I 1 1.11/15/11 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2007 - 2011 Hazmat Fee $425.00 380 1 1, 042000.0 <br /> 230 042000.0 Hazmat Penalty Fee $42.50 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $467.50 <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 /> CANELO'S MARKET 209-981-2538 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2031 S EL DORADO ST STOCKTON CA 95206-2733 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CANELO'S MARKET 209-981-2538 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2031 S ELDORADO ST STQC TON CA 95206-2733 <br /> REPARED BY CHECKED BY ATE Coy. 20(area) <br />