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CPG # TO: 'ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL © py <br /> ACCOUNT NO. DE%MI <br /> EFERRAL <br /> 02 <br /> LAST - GUARANTOR - FIRSTLE LAST - AKA - FIRST <br /> MI TITLE <br /> LUCERO TRUCKING <br /> C/O NAME GUARANTOR SSN <br /> =RESIDENCESTREET <br /> CITY ST ZIP CODE AREA PHONE NO. <br /> 739 LINDEN CA 95236 <br /> CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO, BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PROB <br /> 13516 HAZMAT 7/15/09 <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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2008 & 2009 Annual <br /> Hmmp Fee $480.00 <br /> 2 Chems @ $15.00 t � <br /> Each Year $60.00 <br /> 10% Late Charge $54.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $618.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTOLIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LUCERO TRUCKING <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4242 E MARIPOSA RD STOCKTON CA 95215 <br /> SPOUSE CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LUCERO TRUCKING <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4242 E MARIPOSA RD STOCKTON /� ,pt 2d 0 CA 1 95215 <br /> V- - <br /> REPARED BY CHECKED BY DATE COL. <br />