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TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COP <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRAL �..e U <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> STOCKTON ROOFING CO INC <br /> CIO NAME GUARANTOR SSN <br /> C A LEASE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> STOCKTON ROOFING CO INC P.O. BOX 1169 STOCKTON CA 95201 209-639-3641 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 117 FOUNTAIN AVE PACIFIC GROVE CA 93950 831-373-4383 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 15/12 <br /> 2221 HAZMAT 3/ <br /> COLIURGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVIC DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $255.00 Pq 4 00 .0 <br /> 30 014290010 Hazmat Penalty Fee $25.50 p8q 04 00 .0 <br /> �8q I q42900to State Surcharge Fee $24.00 p8q 4 00 .0 <br /> p8q 0 2 0010 Electronic Surcharge Fee $25.00 p8q 4 00 .0 <br /> 80 0 290010 8 4 <br /> 80 1 014290010 Pq 4 00 .0 <br /> 80 1 0 2 00. 8q 1 P43009.01 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> nnR ail <br /> ZIP CODE <br /> PRIOR STREET <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> STOCKTON ROOFING CO INC 209-639-3641 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2712 E FREMONT ST STOCKTON CA 95205 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> STOCKTON ROOFING CO INC 209-639-3641 <br /> EMPLOYERSTREET <br /> 2712 E FREMONT ST STOCKT N CA 95205 <br /> CHECKED BY JDAIF .1 COL 28 (3188) <br />