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C2G # TO: OFFICE OF REVENUE AND RECOVERY ACCOUNT TRANSMITTAL <br /> DEPcopy <br /> ACCOUNT NO. T.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GREEN HORIZON <br /> CIO NAME GUARANTOR SSN <br /> GREEN HORIZON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> GREEN HORIZON 611 GILMORE ST STOCKTON CA 95201 415-255-0107 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 540 FILLMORE STREET SAN CA 94117 415-255-0107 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATEI BMd CBMd INd MONTHLY PAY AMT <br /> 14177 HAZMAT 3/15/12 <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 /> 230 042000.0 2012 Hazmat Fee $270.00 Pq I pa 3009-01 <br /> 30 014290010 1 Hazmat Penalty Fee $27.00 38q1043009.01 <br /> p8q I q429OOtO I State Surcharge Fee $24.00 38q <br /> p8q 1 0 29001 0 Electronic Surcharge $25.00 P89 <br /> 1 1 <br /> 8� 1 C�421Q0010 I P89 <br /> 1 1 <br /> 8 2 00 0 I p8q <br /> 8 O�240010 1 p8q400 .0 <br /> 1 1 <br /> TOTAL $346.00 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GREEN HORIZON 415-255-0107 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 611 GILMORE AVE STE B STOCKTON CA 95201 <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 /> GREEN HORIZON 415-255-0107 <br /> EMPLOYER STREET <br /> 611 GILMORE AVE STE�B STC�CTONCA 1 95201 <br /> CHECKED BY IDATE COL. 20 (3188) <br />