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CPG # TO: .OFFICE OF REVENUE AND RECOVERY - <br /> t ACCOUNT TRANSMITTAL copy <br /> ACCOUNT NO. DEPT. NO. REFERRAL026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> E&A TIRE&AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> EDWIN LAVAGNINO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4304 E FREMONT ST STOCKTON CA 95215 209-467-3343 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4304 E. FREMONT ST. STOCKTON CA 95215 209-986-1666 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I MT P <br /> 14279 HAZMAT 1.4/15/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> mn <br /> 230 042000.0 2011 Hazmat Fee $100.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $10.00 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $585.00 <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 /> E&A TIRE &AUTO REPAIR 209-467-3343 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4304 E FREMONT ST STOCKTON CA 95215 <br /> CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> E&A TIRE&AUTO REPAIR 209-467-3343 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4304 E FREMONT ST STOC T N CA 95215 <br /> PREPARED BY CHECKED BY DATE �J,:2 7- coy. 20 Iareal <br />