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CPG ,# TO: O` -CE OF REVENUE AND RECOVERY � c �� pc) <br /> n /�TRANSMITTAL 1\/t\�\//�\/t \111V11(/ <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> COLLINS ELECTRICAL CO INC <br /> C/O NAME GUARANTOR SSN <br /> EUGENE C GINI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> COLLINS ELECTRICAL CO INC 611 W FREMONT ST STOCKTON CA 95203 209-466-3691 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 611 W FREMONT ST STOCKTON CA 95203 209-466-3691 <br /> USER REFERENCE NO. IBILL kTAT ICYCLE ISTATUS DATEI BMd CBMI IN MONTHLY PAY AMT PRm <br /> 3748 HAZMAT 1.3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE R CIPIENT USERREFERENCE 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 /> WA <br /> 230 042000.0 - 2012 Hazmat Fee $360.00 8 1 P43009.01 <br /> 30 1 014290010 1 Hazmat Penalty Fee $0.00 P89L043109-01 <br /> 8 42 00 0 Sm Hw Gen <5 Tons/yr $213.00 P89 <br /> �8q 1 014290010 Permit Fee Penalty $213.00 8 1 P43009.01 <br /> s0 0 2 0010 1 State Surcharge Fee $24.00 1 p8q4 00 .0 <br /> 80 1 0 2 00 o Electronic Surcharge Fee $25.008 4300 .0 <br /> 80 0 2 00. Payment -$409.00 8 4 00 .0 <br /> TOTAL $426.00 <br /> PRIOR STREET rITY IT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> COLLINS ELECTRICAL CO INC 209-466-3691 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 611 W FREMONT ST STOCKTON CA 95203 <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 /> COLLINS ELECTRICAL CO INC 209-466-3691 <br /> EMPLOYER STREET r.1TV ST 71P Q.QnF <br /> 611 W FREMONT STS C,KT CA 95203 <br /> PRF:PARFn g L, 1, Ccoi zo(a�ee) <br />