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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL Co py <br /> ACCOUNT NO. REFERRAL <br /> DEPT. NO. <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PIZZA FACTORY <br /> C/O NAME GUARANTOR SSN <br /> DANIEL NEHER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PIZZA FACTORY P.O. BOX 1700 IONE CA 95640 209-607-7787 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 14088 E HWY 88 LOCKEFORD CA 95237 209-607-7787 <br /> USER REFERENCE NO. BILL TAT ICYCLE ISTATUS DATEI BMd CBMd INTI MONTHLY PAY AMT <br /> 13089 HAZMAT 3/20/11 <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 DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 1 1 oa20DD.D Electronic Surcharge $25.00 <br /> 1 1 042000.0 Hazmat Penalty Fee $25.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 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 /> PIZZA FACTORY 209-607-7787 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 14088 E HWY 88 LOCKEFORD CA 95209 <br /> S-PAUS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PIZZA FACTORY 209-607-7787 <br /> EMPLOYER STREET I CITY ST ZIP CODE <br /> 14088 E H WY 88 LOCKEF RDCA 95209 <br /> REPARED BY CHECKED BY DATE J '// COL zo laiee7 <br />