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CPG # TO: —FICE OF REVENUE AND RECOVERY <br /> _ ACCOUNT TRANSMITTAL �... COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BROWER DURABLE TRANSMISSIONS, <br /> C/O NAME GUARANTOR SSN <br /> C RAY BROWER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1204 ENTERPRISE ST STOCKTON CA 95204 209-610-6075 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3118 ESTATE DRIVE STOCKTON CA 95209 209-610-6075 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT PYM <br /> 732 HAZMAT 1 1.3/15/09 <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 /> CHARGEmn DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $70.00 - <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $11.50 <br /> State Surcharge Fee $24.00 <br /> Sm Hw Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $576.50 <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 /> BROWER DURABLE TRANSMISSIONS, INC 209-610-6075 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1204 ENTERPRISE ST STOCKTON CA 95204 <br /> S-POU4& 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 /> BROWER DURABLE TRANSMISSIONS, INC 209-610-6075 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1204 ENTERPRISE ST STOCKTON CA 95204 <br /> PREPARED BY CHECKED BY PATE O 9 COL. 20 (3W) <br />