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CPG^4 TO: O CE OF REVENUE AND RECOVERY <br /> ` a TRANSMITTAL C (OPY <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> R&S TRANSMISSION <br /> CIO NAME GUARANTOR SSN <br /> MARIO&MARICELA REYNOSO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 24572 S MACARTHUR DR TRACY CA 95376 209-403-2093 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 6123 BREA AVE STOCKTON CA 95207 209-403-2093 <br /> USER REFERENCE NO. BILL STAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> TERM DA <br /> 14299 HAZMAT 3115112 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATIVE <br /> PGA <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGEDEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $85.00 8 4 00 .0 <br /> 30 042 000 Haz Mat Penalty Fee $8.50 P8904 00 .0 <br /> 8 42 000 Sm Hw Gen <5 Tons/yr $213.00 p8q <br /> 1 1 <br /> p8q 1 0 2 o0 0 1 Permit Fee Penalty $213.00 p8q4 009.01 <br /> 8 0 2 00 o State Surcharge Fee $24.00 8q 1 P43009.01 <br /> 80 1 0 2 00 o I Electronic Surcharge Fee $25.40 p8q <br /> 80 I 0 2 00 8 4 00 .0 <br /> TOTAL $568.50 <br /> PRIOR STREET CIjy S1 ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> R&S TRANSMISSION 209-403-2093 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 24572 S MACARTHUR DR TRACY CA 95376 <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 /> R&S TRANSMISSION 209-403-2093 <br /> EMPLOYER STREET CITY 71P QQF)F <br /> 24572 S MACARTH RP5,ZR�JC 95376 <br /> C ECKED BY DATE COL. 20 <br />