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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL f�1 pyACCOUNT <br /> NO. DEPT. N� REFERRA (�/\`vJ)\)� <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JERRY JOY CONCRETE <br /> C/O NAME GUARANTOR SSN <br /> COLLEEN JOY <br /> MAILING STREET CITY ST ZIPCODE AREA PHONE NO. <br /> JERRY JOY CONCRETE 3028 CANAL DR STOCKTON CA 95204 209-462-1481 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3028 CANAL DRIVE STOCKTON CA 95204 209-462-1481 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMINT MONTHLY PAY AMT <br /> 12088 HAZM AT 1.3/20/1.0 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <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 $345.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $34.50 <br /> TOTAL $428.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHO" <br /> JERRY JOY CONCRETE 209-462-1481 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 4900 E MARIPOSA RD STE C STOCKTON CA 95215 <br /> SPAUSB CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JERRY JOY CONCRETE 209-462-1481 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4900 E MARIPOSA RD STE C TOCKTONCA 95215 <br /> REPARED BY CHECKED BY DATE a 3/fid COL n (y ) <br />