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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRAL `� <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> QWEST COMMUNICATIONS CORP <br /> C/O NAME GUARANTOR SSN <br /> QWEST COMMUNICATIONS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> QWEST COMMUNICATIONS CORP 1801 CALIFORNIA ST DENVER CO 80202 206-346-7532 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1801 CALIFORNIA STREET, SUITE 1160 DENVER CO 80202 303.902.7091 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMd INT MONTHLY PAY AMT <br /> 8778 HAZMAT 1.3/20/1 <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 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 milk IL w <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> QWEST COMMUNICATIONS CORP 206-346-7532 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 952 E LINDSAY ST STOCKTON CA 95202-2644 <br /> S�P6U,SE� CO—OWNER <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 /> QWEST COMMUNICATIONS CORP 206-346-7532 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 952 E LINDSAY ST STOCKTO CA 95202-2644 <br /> REPARED BY CHECKED BY ATE (��+ Jl �� COL. W (3W) <br />