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E OF REVE <br /> AND <br /> UE <br /> CPG # To: WC ACCOUNTNTRANSMITTALRY C oy <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BERNICK MECHANICAL <br /> C/O NAME GUARANTOR SSN <br /> RICK ABRAHAMSON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> BERNICK MECHANICAL 1040 W KETTLEMAN LN LODI CA 95240 209-334-1960 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1743 LAKESHORE DRIVE LODI CA 95242 209-334-1960 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMCBM INT MONTHLY PAY AMT PYMT PROB <br /> 13474 HAZMAT 7/15/09 <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 /> 230 026000.0 2007-2009 Annual <br /> Hmmp Fee $720.00 <br /> 1 Chem @ $15.00 <br /> Each Year $45.00 <br /> 10% Late Charge $76.50 ' <br /> State Surcharge Fee $24.00 <br /> TOTAL $865.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONENO <br /> BERNICK MECHANICAL 209-334-1960 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 1621 NAVY DR BLDG#6 STOCKTON CA 95206 <br /> SPOUSE CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BERNICK MECHANICAL 209-334-1960 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1621 NAVY DR BLDG#6 STOCKTON � '' C CA 95206 <br /> PREPARED BY , CHECKED MY 12ATE COL 20 (3193) <br /> �. <br /> Cori <br />