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01GI# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL �..I copy <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> STOCKTON ROOFING CO INC <br /> C/O 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 <br /> Tg!!!21\A CBMHINIONTHLY PAY AMT <br /> PYM PR B <br /> 2221 HAZMAT 4/15/11 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $255.00 380 042000.0 <br /> R380 <br /> 042000.0 Haz Mat Penalty Fee $25.50 380 042000.0 <br /> 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 042000.0 380 042000.0 <br /> TOTAL $755.50 <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 /> STOCKTON ROOFING CO INC 209-639-3641 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2712 E FREMONT ST STOCKTON CA 95205 <br /> 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 /> STOCKTON ROOFING CO INC 209-639-3641 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2712 E FREMONT ST ST I CA 95205 <br /> REPARED BY CHECKED BY DATE �_// coL. 20 Isresl <br />