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CPG # TO: FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • COPY <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 SSN <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. BILL TAT CYCLE STATUS DATE BM CBMCINT MONTHLY PAY AMT PYMT PROB <br /> 6139 HAZMAT 4/15/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> MED REC NO <br /> START STOP CHARGE <br /> CHMn ARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $285.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $28.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 1, 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 1 11 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $788.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2489 E MINER AVE STOCKTON CA 95205 <br /> CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2489 E MINER ;VES N CA 95205 <br /> REPARED BY CHECKED BY DATE ��� '�1 cor zo t3reel <br />