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CPG # TO: --FICE OF REVENUE AND RECOVERY <br /> " „ ACCOUNT TRANSMITTAL 1.004 <br /> CO PY <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> FREMONT SHELL <br /> C/O NAME GUARANTOR SSN <br /> MICHAEL A DOMINGUEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2494 E FREMONT ST STOCKTON CA 95205 209-941-8743 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2494 E. FREMONT ST STOCKTON CA 95205 209-941-8743 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATEI BMd CBMd INT MONTHLY PAY AlT PRIATP <br /> 8666 HAZMAT 11 11 LL I I I I 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 /> CHARGEDEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $13.00 <br /> State Surcharge Fee $24.00 <br /> Sm Hw Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $593.00 <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 /> FREMONT SHELL 209-941-8743 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 2494 E FREMONT ST STOCKTON CA 95205 <br /> SPOUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FREMONT SHELL 209-941-8743 <br /> EMPLOYER STREET CITY I ST ZIP CODE <br /> 2494 E FREMONT ST STOCKTON I CA 95205 <br /> PREPARED BY I CHECKED BY P2ATE �� 6� COL 20(3IBB) <br />