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CPG # - TO: P- ICE OF REVENUE AND RECOVERY <br /> NO ACCOUNT TRANSMITTAL ..s COPY <br /> ACCOUNT NO. DEPT, NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JERRY JOY CONCRETE 1 11 ill ] 1111AII <br /> C/O NAME GUARANTOR SSN <br /> COLLEEN JOY <br /> MAILING STREET CITY ST ZIP CODE 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 BMI CBMd INT MONTHLY PAY AMT PYMTr I PROB <br /> 12088 HAZMAT 3/15/09 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 7 Chems @ $15.00 Each $105.00 <br /> 10% Late Charge $34.50 <br /> State Surcharge Fee $24.00 <br /> TOTAL $403.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JERRY JOY CONCRETE 209-462-1481 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4900 E MARIPOSA RD STE C STOCKTON CA 95215 <br /> SPAUSS CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 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 STOCKTON CA 95215 <br /> REPARED BY CHECKED BY DATE ./ Z j 67. COL. 20(3/88) <br /> 7� <br />