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CeC •+ TO: OFx'TCE OF REVENUE AND RECOVERY Copy <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT N0. DEPT.NO. REFERRAL <br /> 026000.0 <br /> jGARLIC <br /> - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BROTHERS RESTAURANT& <br /> NAME GUARANTOR SSTN <br /> GREGORY RISSO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 6629 EMBARCADERO STOCKTON CA 95219 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 3/15/12 <br /> 13848 HAZMAT <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $255.00 8 4 <br /> 30 042 00 0 Hazmat Penalty Fee $25.50 p8q 04 00 .0 <br /> 5 42 00 o State Surcharge Fee $24.00 8 4 00 .0 <br /> 8 0 2 00 0 Electronic Surcharge $25.00 8 4 00 .0 <br /> 80 0 290010 8 4 00 .0 <br /> 80 0 2 00 0 8 4 00 .0 <br /> 80 0i42q00.p P43009.0, <br /> TOTAL $329.50 <br /> GUARANTOR <br /> nnR <br /> ZIP CODE <br /> PRIOR STREET <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GARLIC BROTHERS RESTAURANT& BAR <br /> EMPLOYER STREET CITY `:FG <br /> T ZIP CODE <br /> 6629 EMBARCADERO STOCKTON CA 95219 <br /> ESTjE FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> EMPLOYER PHONE NOTAURANT& BAR <br /> 6629 EMBARCADERO STOC N CA 95219 <br /> CHECKED BY DA coy. Xlaieel <br />