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CPG # TO: OF 'E OF REVENUE AND RECOVERY <br /> " Pf <br /> T.NO. TRANSMITTAL OACCOUNT NO. DEPREFERRAL : <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 /> PYMT <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE BMd CBMd IN MONTHLY PAY AMT <br /> 8666 HAZMAT 3/15/12 <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 aCHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NR I'll <br /> 230 042000.0 2012 Hazmat Fee $130.00 a oo .030 042 000 Hazmat Penalty Fee $13.00 oa 00 .08 42 000 Sm Hw Gen <5 Tons/yr $213.00 a 00 .08 0 2 000 Permit Fee Penalty $213.00q P4;009.0 <br /> 8 014290010 State Surcharge Fee $24. p8q P44009.01 <br /> 80 I 0 2 00 0 I Electronic Surcharge Fee $25.00 89 P43009.0, <br /> 80 1 002400-P 8 4 00 .0 <br /> TOTAL $618.00 <br /> PRIOR STREET ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> FREMONT SHELL 209-941-8743 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2494 E FREMONT ST STOCKTON CA 95205 <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 /> FREMONT SHELL 209-941-8743 <br /> EMPLOYER STREET CITY ST 71P C.QDF <br /> 2494 E FREMONT ST STOCK ON CA 95205 <br /> CHECKED BY DATE COL. 20 (3188) <br />