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CP.G # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CALIFORNIA GAS STATION LLC <br /> C/O NAME GUARANTOR SSN <br /> ROSHAN MINHAS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2420 W GRANT LINE RD TRACY CA 95376 209-640-7082 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1484 GABLE CT TRACY CA 95376 209-832-8273 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBM INT MONTHLY PAY AMT I ,PYM R B <br /> A nATF <br /> 12451 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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $270.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $27.00 380 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 II 042II 000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $772.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CALIFORNIA GAS STATION LLC 209-640-7082 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2420 W GRANT LINE RD TRACY CA 95376 <br /> CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CALIFORNIA GAS STATION LLC 209-640-7082 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2420 W GRANT LINER TRAC CA 1 95376 <br /> PREPARED BY CHECKED BY DATE A. 7��� COL13ml)) <br />