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CPG # - T0: ICE OF REVENUE AND RECOVERY <br /> FCOPY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 11 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MID-CAL CONSTRUCTION INC <br /> C/O NAME GUARANTOR SSN <br /> MID-CAL CONSTRUCTION INC <br /> 11 I <br /> MAILING STREET CITY ST ZIPCODE AREA PHONENO. <br /> 2716 E MINER AVE #SSTOCKTON CA 95205 209-832-4400 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2716 E. MINER AVE., STE. S STOCKTON CA 95205 209-832-4400 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMd INT MONTHLY PAY AMT I PYMT PM n <br /> ATF <br /> 13917 HAZMAT 3/20/11 <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 /> 380 042000.0 2011 Hazmat Fee $285.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $28.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380042000.0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MID-CAL CONSTRUCTION INC 209.832-4400 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2716 E MINER AVE#S STOCKTON CA 95205 <br /> SPOU-99 CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO I AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> M ID-CAL CONSTRUCTION INC 209-832-4400 <br /> EMPLOYER STREET I CITY ST ZIP CODE <br /> 2716 E MINER AVE#S STOCKTON CA 95205 <br /> PREPARED BY CHECKED B - DATE ) r) // COL 20 (318e) <br />