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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • <br /> ACCOUNT NO. 0260000. REFERRAL <br /> 026000.0 I'uFL-J^/ V <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> J&M TRANSMISSIONS <br /> C/O NAME GUARANTOR SSN <br /> MAURICIO URTEAGA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 7944 W 11TH ST #FTRACY CA 95304 209-833-7955 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4196 ESCATTA AVE TRACY CA 95377 209-833-7955 <br /> USER REFERENCE NO. BILL TATCYCLE STATUS DATE SMd CBM INT MONTHLY PAY AMT I PYM <br /> IF DAT TrghfinATP <br /> 8722 HAZMAT 1.3/20/1,0 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> E2330 <br /> STOP MED REC NO CHARGE <br /> DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 026000.0 Sm Hw Gen<5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $85.00 77 .1 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL 1 $568.50 <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 /> J&M TRANSMISSIONS 209-833-7955 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 7944 W 11 TH ST#F TRACY CA 95304 <br /> SP6H-S& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> J&M TRANSMISSIONS 209-833-7955 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 7944 W 11TH ST#F TR Y/,. CA 95304 <br /> REPARED B CHECKED BY ATE / S' ./0 COL. 20 (3/BB) <br />