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------- <br /> CPG # TO: 01 CE OF REVENUE AND RECOVERY <br /> ACCOUNT NO. REFERRAL <br /> ^� <br /> TRANSMITTAL ""' o O <br /> DEPT.NO. <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MANTECA AUTO PLAZA <br /> C/O NAME GUARANTOR SSN <br /> MICHAEL G PETERS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> MANTECA AUTO PLAZA P.O. BOX 1286 MANTECA CA 95336 209-239-7777 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1190 S. MAIN MANTECA CA 95337 209-239-7777 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> 10113 HAZMAT I 1 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE D DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NR <br /> 230 042000.0 2012 Hazmat Fee $360.00R�89 P4;009.0 <br /> 30 014290010 Hazmat Penalty Fee $36.00 P43009-01 <br /> 6 42 00 o Sm Hw Gen <5 Tons/yr $213.004 00 .o8 0 2 00o Permit Fee Penalty $213.00 a 00 .080 0 2 000 State Surcharge Fee $24.00 4 00 .0 <br /> j 11 <br /> 8 0I42q0010 I Electronic Surcharge Fee $25.00 P89 <br /> 80 0 2900,p 8P43009.01 11 <br /> TOTAL $871.00 <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MANTECA AUTO PLAZA 209-239-7777 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 1190 S MAIN ST MANTECA CA 95336 <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 /> MANTECA AUTO PLAZA 209-239-7777 <br /> EMPLOYER STREET CITY <br /> 1190 S MAIN ST MANTE �kZCA 95336 <br /> CHECKED BY IDATE COL. 20 (3188) <br />