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CPG # _ TO: OOCE OF REVENUE AND RECOVERY ArrOTTNT TRANSMITTAL // O [py <br /> ACCOUNT NO. DEPT.NO. REFERRAL1\\,_ 0 <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> DOUBLE D CUSTOM <br /> C/O NAME GUARANTOR SSN <br /> DANIEL DUARTE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> DOUBLE D CUSTOM 335 E KETTLEMAN LN LODI CA 95240 209-369-2838 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1340 CANDLEWOOD WAY STOCKTON CA 95209 209-595-0311 <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE BMd CBM ]NJ MONTHLY PAY AMT <br /> 13974 HAZMAT 1, 3/15/12 <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 /> pip IV) <br /> 230 042000.0 2012 Hazmat Fee $85.00 p8q 043002.0, <br /> 30 1 014290010 1 Hazmat Penalty Fee $8.50 P1q 04 00 .0 <br /> 8q42900,0 Sm Hw Gen <5 Tons/yr $213.00 38q <br /> 1 1 <br /> 8 0 2 90010 1 Permit Fee Penalty $213.00 2189 <br /> 80 1 014290010 State Surcharge Fee $24.00 p8q <br /> 1 1 <br /> 80014290010 Electronic Surcharge Fee $25.00 p8q <br /> 1 1 <br /> 80 1 0 2 00. Pq 11 P43009-01 <br /> TOTAL $568.50 <br /> Gaul RANTOR. <br /> PRIOR STREET r.ITY AT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DOUBLE D CUSTOM 209-369-2838 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 335 E KETTLEMAN LN BLDG A STE D LODI CA 95240 <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 /> DOUBLE D CUSTOM 209-369-2838 <br /> EMPLOYER STREET CITY ST 71P(,.onF <br /> 335 E KETTLEMAN yN BLDG F}STE D LODI CA 95240 <br /> CHECKED BY JDATE ,I COQ. 20 13188: <br />