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CPG # TO: FICE OF REVENUE AND RECOVERY <br /> aww ACCOUNT TRANSMITTAL ...� CO P <br /> n/JACCOUNT NO. DEPT.NO. REFERRAL V <br /> 026000.0 1 DATE I <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> RIVERA AUTO SERVICE <br /> C/O NAME GUARANTOR SSN <br /> ARMANDO RIVERA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1402 E MINER AVE STOCKTON CA 95205-4535 209-942-3085 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1632 S SAN JOAQUIN ST STOCKTON CA 95206 209-942-3085 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> Dt IF DATE TERM DATE <br /> 12757 HAZMAT 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DE T.N DESCRIPTION AMOUNT <br /> NO <br /> 230 026000.0 2008 Hmmp Annual Fee $70.00 '1., <br /> 1 Chem @ $15.00 Each $15.00 <br /> 10% Late Charge $8.50 <br /> State Service Fee $24.00 <br /> Use Oil Only - <5 Tons/yr $54.00 <br /> Permit Fee Penalty $54.00 <br /> TOTAL $225.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RIVERA AUTO SERVICE 209-942-3085 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1402 E MINER AVE STOCKTON CA 95205-4535 <br /> &PeUSEl CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RIVERA AUTO SERVICE 209-942-3085 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1402 E MINER AVE STOCKTON CA 95205-4535 <br /> PREPARED BYCHECKED BYDATE cOL. 20 r18e <br /> z ct� `� ti� <br />