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CPG,# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT NO. PT.N <br /> ACCOUNT TRANSMITTAL ..r 0py <br /> DEO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SILVESTRE'S CONST MECH CO <br /> C/O NAME GUARANTOR SSN <br /> SILVESTRE HERNANDEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> SILVESTRE'S CONST MECH CO P.O. BOX 2507 LODI CA 95241 209-327-0749 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3713 MASSIMO CIRCLE STOCKTON CA 95212 209-327-0749 <br /> PYMT <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATEI BMd CBMd INd MONTHLY PAY AMT <br /> 14045 HAZMAT <br /> 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE OF <br /> START STOP MED REG NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT RHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $360.00 4 00 .030 042 000 Hazmat Penalty Fee $36.00 Oa 00 .08 42 000 State Surcharge Fee $24.00 4 00 .08 0 2 00 0 Electronic Surcharge $25.00 1 P43009.01 <br /> 80 11 0II12Q0010 I Cal Arp Surcharge Fee $270.008 4 00 .0 <br /> 8 11 02000 8P43009.01 11 <br /> 80 11 0112q0O.P8 4 00 .0 1 11 <br /> TOTAL $715.00 <br /> GUARANTOR <br /> PRIOR STREET rITY ATZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SILVESTRE'S CONST MECH CO 209-327-0749 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 6030 E KETTLEMAN LN 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 /> SILVESTRE'S CONST MECH CO 209-327-0749 <br /> EMPLOYERSTREET rITV RT 71P(`0nF <br /> 6030 E KETTLEMAN LN ODI CA 95240 <br /> !PREPARED ay t:Z44L�ZC�IVX I CHECKED BY IDATE COL. 20 (N86) <br />