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CPG' fii TO: OFFICE OF REVENUE AND RECOVERY � C� o <br /> �� <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> T. <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> VALLEY BREWING CO <br /> C/O NAME GUARANTOR SSN <br /> KELLIJACOBS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> VALLEY BREWING CO 157 W ADAMS ST STOCKTON CA 95204 209-464-2739 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 157 WEST ADAMS STOCKTON CA 95204 209-464-2739 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS 9DATEJBM !1IT111MONTHLY PAY AMT01 15 DATE <br /> 13694 HAZI 3/15/12 <br /> IZELARZES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICETE: DATE OF <br /> STARTSTOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NA <br /> 230 042000.0 2012 Hazmat Fee $315.00 8q 1 P43009.01 <br /> 30 1 014290010 Hazmat Penalty Fee $31.50 P89104300P.0 <br /> �8q I q429OOrO I State Surcharge Fee $24.00 I218q <br /> 8 2 00 0 Electronic Surcharge $25.00 8 a 00 .0 <br /> 8 0I42q0010 I 218q <br /> ?8q I 0 2 000 1 P43009.01 <br /> 60 1 002qOO-p 1 P43009-0 <br /> TOTAL $395.50 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> VALLEY BREWING CO 209-464-2739 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 1950 W 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 /> VALLEY BREWING CO 209-464-2739 <br /> EMPLOYER STREET CITY ST 71P QQDF <br /> 1950 W FREMONT ST ST C N CA 95203 <br /> ED BY IDATE co 20 (3188) <br />