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CPG;# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • <br /> ACCOUNT NO. DEPT. NO. REFERRAL COPY 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> WOODBRIDGE PIZZERIA <br /> C/O NAME GUARANTOR SSN <br /> ELIZABETH CASTILLO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> WOODBRIDGE PIZZERIA P.O. BOX 14 WOODBRIDGE CA 95258 209-603-1528 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1110 W. KETTLEMAN LN. #2 LODI CA 95240 209-603-1528 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT PYMT PROB <br /> 14363 HAZMAT <br /> 3/20/11 <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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $25.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $329.50 <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 /> WOODBRIDGE PIZZERIA 209-603-1528 <br /> EMPLOYER STREET CITY ;CA <br /> ZIP CODE <br /> 1110 W KETTLEMAN LN #48 LODI 95240 <br /> SFBi�&Fo- 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 /> WOODBRIDGE PIZZERIA 209-603-1528 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1110 W KETTLEMAN 48 I CA 1 95240 <br /> REPARED BY CHECKED BY ATE l� %� coy. 20 131881 <br />