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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL 0 <br /> ACCOUNT NO. DEPT. NO. REFERRAL py <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BRENICK MECHANICAL 1 11 11 1 <br /> C/O NAME GUARANTOR SSN <br /> RICK ABRAHAMSON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> BRENICK MECHANICAL 1040 W KETTLEMAN LN 1 B#142 1 B-142 LODI CA 95240 209-334-1960 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1040 W. KETTLEMAN LN. 1B-142 LODI CA 95240 209-334-1960 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INd MONTHLY PAY AMT PYMT PRO <br /> 14644 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTOR USER REFERENCE NO/NARRATIVE <br /> r <br /> E DATE: DATE OF <br /> STOP MEDRECNO CHARGE <br /> DEPT.NO. DESCRIPTION AMOUNT RHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NA <br /> 042000.0 2012 Hazmat Fee $255.00 4 00 .0 Oat 000 Hazmat Penalty Fee $25.50 Oa 00 .01 1 <br /> 42 000 State Surcharge Fee $24.00 4 00 .00 2 00 0 Electronic Surcharge $25.00 4 00 .0 <br /> 80 0 2 000 q 044009.0 <br /> 80 1 0 290010 8q 043009.0 <br /> 8 0200. 8 400 .0 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BRENICK MECHANICAL 209-334-1960 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1621 W NAW DR#2 STOCKTON CA 95206 <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 /> BRENICK MECHANICAL 209-334-1960 <br /> EMPLOYER STREET CITY 71P(',ODF <br /> 1621 W NAW DR#2STOC TON CA 95206 <br /> CHECKED BY IDATE I COL 20 (3/B8J <br />