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CPG # TO: C CE OF REVENUE AND RECOVERY _ <br /> TRANSMITTAL C L1 <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GOLDEN GATE ORN IRON WORKS <br /> C/O NAME GUARANTOR BSN <br /> JESUS T VALENZUELA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2489 E MINER AVE STOCKTON CA 95205 209-941-4090 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-941-4090 <br /> USER REFERENCE NO. IBILL kTAT ICYCLE STATUS DATEI BMd CBMI INd MONTHLY PAY AMT <br /> 6139 HAZMAT 11 1 1 1 1 1 1 1 1 1 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE --RECIPIENT USER REFERENCE NOMARRATIVE <br /> S <br /> ERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> MR <br /> 042000.0 2012 Hazmat Fee $285.00 8P43009.01 <br /> 042 00o Hazmat Penalty Fee $28.50 8 o4 00 .o 42 00o Sm Hw Gen <5 Tons/yr $213.00 8 a 00 .0 0 2 00 0 I Permit Fee Penalty $213.00 p8q P44009.0, <br /> 80 0 2 00 0 State Surcharge Fee $24.00 p8q j43009.0, <br /> 80 0 290010 Electronic Surcharge Fee $25.00 p8q4 00 .0 <br /> 80 1 0 2 00.p 1 �8q 1 P43009.01 <br /> TOTAL $788.50 <br /> PRIOR STREET CITY ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 2489E MINER AVE STOCKTON CA 95205 <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 /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYER STREET <br /> 2489E MINER AVE ST N CA 95205 <br /> Rr <br /> CHECKED BY IDATE COL 20 (MB) <br />