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CPG•# TO: OFFICE OF REVENUE AND RECOVERY <br /> �.. ACCOUNT TRANSMITTAL C O py <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> NICA METALS <br /> C/O NAME GUARANTOR SSN <br /> HAROLD MENDOZA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> NICA METALS 248 INDUSTRIAL DR STOCKTON CA 95206 209-234-4300 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO. <br /> 248 INDUSTRIAL DRIVE STOCKTON CA 95206 209-234-4300 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE I BM CBM INT MONTHLY PAY AMT nj PYMTnATP P <br /> OB irTPPhAnATP <br /> 13789 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 /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $345.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $34.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $854.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> NICA METALS 209-234-4300 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 248 INDUSTRIAL DR STOCKTON CA 95206 <br /> SPOUSE- CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> NICA METALS 209-234-4300 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 248 INDUSTRIA ST CKTO�+f CA 95206 <br /> PREPARED BY I CHECKED BY IDATE COL. 9n (MR) <br />