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CPG' # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NOO 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 BMd CRMd INT MONTHLY PAY AMT PV T PRO13 <br /> 12451 HAZMAT 3/20/10 <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 /> CHKin ARGE DEPT. NO. DESCRIPTION AMOUNT _CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5 Tons/yr $213.00 Hazmat Penalty Fee $27.00 <br /> 2010 Hazmat Fee $270.00 Permit Fee Penalty $1013.00 <br /> Ust State Surcharge Fee $45.00 <br /> Additional Ust $250.00 <br /> List Facility & 1 Tank $550.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> TOTAL $2417.00 <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 I ZIP CODE <br /> 2420 W GRANT LINE RD TRACY CA 95376 <br /> 8P4nWb& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAMEI I I <br /> EMPLOYER PHONE NO <br /> CALIFORNIA GAS STATION LLC 209-640-7082 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2420 W GRANT LINER TR, Y CA 95376 <br /> REPARED BY [ CHECKED BY DATE �S—�O COL. 20 laieel <br />