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-CPG T0: OFFICE OF REVENUE AND RECOVERY Py <br /> ACCOUNT TRANSMITTALACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GARLIC BROTHERS RESTAURANT & <br /> C/O NAME GUARANTOR SSN <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 8M CBM INT MONTHLY PAY AMT <br /> p7nmATTF <br /> 13848 HAZMAT <br /> 4/15/11 <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 Kin DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT, NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $255.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $25.50 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380042000.0 380 042000.0 <br /> TOTAL $329.50 <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 /> GARLIC BROTHERS RESTAURANT& BAR <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 6629 EMBARCADERO STOCKTON CA 95219 <br /> CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GARLIC BROTHERS RESTAURANT& BAR <br /> EMPLOYER STREET CITY EST ZIP CODE <br /> 6629 EMBARCADER TO TON CA 95219 <br /> PREPARED BY CHECKED BY DATE 7 7�� ca. x Iasel <br />