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CPG # TO: 0 CE OF REVENUE AND RECOVERY <br /> "` C' (D FlDly TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> A-CARE AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> GERALD TRIP <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1102 W FREMONT ST STOCKTON CA 95203 209-463-5600 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1102 W. FREMONT STOCKTON CA. 95203 209-463-5600 <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE Bmd CBMd IN MONTHLY PAY AMT �Y�,ITP 11 TPR44 DATE <br /> 14647 HAZMAT 1 11 11 1 1 1 1 1 1 1 1 1 1 1 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE TrECIPIENT USER REFERENCE NO/NARRATIVE <br /> 99 <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> r <br /> DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 042000.0 2012 Hazmat Fee $85.00 8 4 00 .0 042 000 Hazmat Penalty Fee $8.50 8 Oa 00 .01 1 <br /> 42 000 Sm Hw Gen <5 Tons/yr $213.00 8 a 00 .0014290010 Permit Penalty Fee $213.00 p8q P43009-0, <br /> 80 0 2 00 0 State Surcharge Fee p8q P4300P.01 <br /> 8 0 290010 Electronic Surcharge Fee $25.00 8 4 00 .0 <br /> 80 0 2 00. 8 4 00 .0 <br /> TOTAL $568.50 <br /> MTA R-ANTOR. <br /> 5 JI I <br /> PRIOR STREET IT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A-CARE AUTO REPAIR 209-463-5600 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1102W FREMONT ST STOCKTON CA 95203 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A-CARE AUTO REPAIR 209-463-5600 <br /> EMPLOYER STREET qT 71P <br /> 1102 W FREMONT ST ST CK7 CA 95203 <br /> :CKED BY InATP COL. 20 (3/88) <br />