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CPG -# TO: OFFICE REVENUE AND RECOVERY � F <br /> ACCC OUNT TRANSMITTAL 11U1( <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 ICYCLE ISTATUS DATE Bmd ATP <br /> CBMd INT MONTHLY PAY AMT I PYMT <br /> 8666 HAZMAT 1.3/20/1.0 <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 /> 230 026000.0 Sm Hw Gen<5 Tons/yr $213.00 Hazmat Penalty Fee $13.00 <br /> 2010 Hazmat Fee $130.00 Permit Fee Penalty $888.00 <br /> LL- <br /> Ust State Surcharge Fee $30.00 <br /> Additional Ust- 2481 $125.00 <br /> Ust Facility& 1tank-2481 $550.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> TOTAL 1 $1998.00 <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 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 I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FREMONT SHELL 209-941-8743 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2494 E FREMONT ST STOC,Kj' CA 95205 <br /> REPARED BY CHECKED BY ATE i 0 1 COL. 20 Israel <br />