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TOOFFICE OF REVENUE & RECOVERY • <br /> CPG: ACCOUNT TRANSMITTAL <br /> ACCOUNT NO DEPT NO REFERRAL DATE <br /> 0420000 <br /> LAST- -GUARANTOR- FIRST MI LAST ANA FIRST MI <br /> Diaz Heriberto C <br /> CIO NAME SSN/FED# DR. LIC.NO. <br /> Beto Auto Repair <br /> MAILING STREET CITY S? ZIP AREA PHONE# <br /> 230 N Pilgrim St Stockton CA 95205 <br /> FACILITY ADDRESS CITY ST <br /> 230 N Pilgrim St Stockton CA 95205 <br /> USER REFERENCE NO <br /> Invoice#238140 <br /> COMMENTS: <br /> SERVICE DATE: <br /> START: 2/1/13 STOP: 2/1/13 <br /> CHARGE DEPT NO DESCRIPTION AMOUNT CHARGE <br /> DEPT NO DESCRIPTION AMOUNT <br /> Inv #238140 <br /> 230 2013 Hazmat Fee 85.00 <br /> 380 State Surcharge Fee 35.00 <br /> 230 Haz Mat Penalty 8.50 <br /> TOTAL 128.50 <br /> EMPLOYER NAME/ OURCE OF INCOME: EMPLOYER PHONE# <br /> EMPLOYER STREET CITY ST ZIP <br /> PREPARED BY: 4acL -c— <br /> REVIEWED BY: DATE: <br />