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CPG, # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL --w c opM <br /> ACCOUNT NO. DEPT.NO. REFERRAL '((ffr J lu-/ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ARTHUR'S PARTY SUPPLY <br /> C/O NAME GUARANTOR SSN <br /> MARK EHLERS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ARTHUR'S PARTY SUPPLY P.O. BOX 8068 STOCKTON CA 95208 209-952-2971 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 8068 STOCKTON CA 95208 209-952-2971 <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATEI BMd CBMd INd MONTHLY PAY AMT <br /> 14698 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1 . 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT ap8q <br /> DEPT.NO. DESCRIPTION AMOUNT <br /> idn <br /> 230 042000.0 2011-2012 Hazmat Fee $540.004 00 .030 042 00 0 Hazmat Penalty Fee $54.00 4 00 .08 42 000 State Surcharge Fee $24.00 4 00 .08 0 2 000 Electronic Surcharge $25.00 <br /> 80 11 0I42q00,0 Bq P4300 .0 <br /> 8 11 0 2 000 11 p8q4 00 .0 <br /> 8 O�2qOO.p p8q400 .0 <br /> TOTAL $643.00 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ARTHUR'S PARTY SUPPLY 209-952-2971 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 615 W GRIDER WAY STOCKTON CA 95210 <br /> ST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYERPHONENO <br /> ARTHUR'S PARTY SUPPLY 209-952-2971 <br /> EMPLOYER STREET CITY 71P r.OnF <br /> 615 W GRIDER WAY STOC T N CA 95210 <br /> -----F-cHEcKED By IDATE GOL. 2011188) <br />