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CPG ;4` TO: ICE OF REVENUE AND RECOVERY <br /> .� ACCOUNT TRANSMITTAL -.4C � PED <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CROSSROADS AUTOMOTIVE <br /> C/O NAME GUARANTOR SSN <br /> BRENT BERKEBILE/SHAYLA FRISBY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 600 N ELDORADO ST STOCKTON CA 95202 209-469-0532 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 600 N. EL DORADO STREET STOCKTON CA 95202 209-469-0532 <br /> USER REFERENCE NO. IBILL kTAT ICYCLE ISTATUS DATEI BM CBM INTI MONTHLY PAY AMT YMT <br /> PROB <br /> 13709 HAZMAT 7/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <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 026000.0 2008 & 2009 Annual <br /> Hmmp Fee $140.00 <br /> 3 Chems @ $15.00 JLW <br /> Each Year $90.00 <br /> 10% Late Charge $23.00 <br /> Statte Surcharge Fee $24.00 <br /> TOTAL $277.00 <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 /> CROSSROADS AUTOMOTIVE 209-469-0532 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 600 N EL DORADO ST STOCKTON CA 95202 <br /> SPOUSE 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 /> CROSSROADS AUTOMOTIVE 209-469-0532 <br /> EMPLOYER STREET ITY ST ZIP CODE <br /> 600 N EL DORADO ST STOCKTON — CA 1 95202 <br /> PREPARED BY I CHECKED 8 DATE COL. 20 (3M) <br /> � d <br />