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CPG, # TO: 0-"'ICE OF REVENUE AND RECOVERY C� o I /�� ACCOUNT TRANSMITTAL "'� V <br /> gLVA <br /> NT NO. T.NO. <br /> REFERRAL <br /> 026000.0 <br /> ANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> RY <br /> GUARANTOR SSN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> DASILVA DAIRY 16880 S HENRY RD ESCALON CA 95320 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NOKUB . <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 12206 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> E C STE: DATE OF <br /> A OP MED RE C NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> WR <br /> 230 042o00.0 Ag Haz Mat Storage Fee $18.00 <br /> 30 014 90010 State Surcharge Fee $24.00 <br /> p8q q4290M Electronic Surcharge $25.00 <br /> p8q I 0I421Q0010 I Sm Hw Gen <5 Tons/yr $213.00 <br /> 80 0 2 goolo Permit Fee Penalty $213.00 <br /> 11 Invoice 110225538 <br /> TOTAL $493.00 <br /> GUARANTOR <br /> PRIOR STREET rITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DASILVA DAIRY <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 16551 S HENRY RD ESCALON CA 95320 <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 /> DASILVA DAIRY <br /> EMPLOYER STREET <br /> 16551 S HENRY RD E CA N CA 95320 <br /> CHECKED 13Y JDATE coL. zo Ia�eel <br />