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CPG # TO: CE OF REVENUE AND RECOVERY • <br /> i ACCOUNT TRANSMITTAL COPY ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST MI TITLE <br /> BETO AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> HERIBERTO C DIAZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 230 N PILGRIM ST STOCKTON CA 95205 209-430-3535 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-430-3535 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE 8M CBMC INT MONTHLY PAY AMT <br /> PYMT PROB <br /> 14270 HAZMAT 3/20/10 <br /> TEI <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> ]. <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. I DESCRIPTION AMOUNT <br /> 230 026000.0 2011 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <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 /> BETO AUTO REPAIR 209-430-3535 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 230 N PILGRIM ST STOCKTON CA 95205 <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 /> BETO AUTO REPAIR 209-430-3535 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 230 N PILGRIM ST STOCKTON CA 95205 <br /> REPARED BY CHECKED BY DATE ,,,,,.�/�� coy. 20 (area) <br />