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CPG' # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ....t copy <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST - MI TITLE LAST - AKA - FIRST MI TITLE <br /> WINE BOTTLE RENEW <br /> C/O NAME GUARANTOR SSN <br /> WINE BOTTLE RECYCLING LLC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2716 E MINER ST STOCKTON CA 95205 209-462-6500 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2716 EAST MINER STREET STOCKTON CA 95205 209-462-6500 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 14539 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> CED E: DATE OF <br /> AR STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $285.00 p8q <br /> 30 1 014190010 1 Hazmat Penalty Fee $28.50 p8q 04 00 .0 <br /> �8q I q42900r0 I State Surcharge Fee $24.00 p8q P43009.01 <br /> 8 0 2 0010 1 Electronic Surcharge $25.00 p8q <br /> 80 0 2 00 0 , p8q 1 P43009.01 <br /> 8 0 2 000 11 p8q <br /> 80 1 0 2qOOp 11 8 4 00 .0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> PRIOR STREET CITY AT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WINE BOTTLE RENEW 209-462-6500 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2716 E MINER ST 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 /> WINE BOTTLE RENEW 209-462-6500 <br /> EMPLOYER STREET CITY ST 71P CnnF <br /> 2716 E MINER ST STOC TO CA 95205 <br /> CHECKED BY JDATE coL. 7o (area) <br />