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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL OO O nY <br /> ACCOUNT NO. DEPT. NO. REFERRAL lur-./ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ALONSO'S AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> HUMBERTO ALONSO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1021 E PARK ST STOCKTON CA 95202 209-941-9026 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-941-9026 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INd MONTHLY PAY AMT <br /> 14265 HAZMAT 1. 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOPMED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NR id(i <br /> 230 042000.0 2012 Hazmat Fee $100.00 p8q 04300 .O <br /> 30 1 014290010 1 Hazmat Penalty Fee $10.00 P89104300P.0 <br /> p8q I q42900rO I State Surcharge Fee $24.00 38q <br /> p8q 1 0 2 00 0 Electronic Surcharge $25.00 p8q <br /> 80 1 0 290010 8P43009.01 <br /> 80 1 014290010 8P43009.01 <br /> 80 1 0lt2q00.p8P44009-01 11 <br /> TOTAL $159.00 <br /> GUARANTOR <br /> PRIOR STREET CITY ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ALONSO'S AUTO REPAIR 209-941-9026 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1021 E PARK ST STOCKTON CA 95202 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ALONSO'S AUTO REPAIR 209-941-9026 <br /> EMPLOYER STREET <br /> 1021 E PARK ST STO TO CA 95202 <br /> CHECKED BY IDATE COL. 20 (3188) <br />