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t <br /> CPG i: TO: OFFICE OF REVENUE AND RECOVERY : Opy <br /> ACCOUNT TRANSMITTAL <br /> t REFERRAL <br /> ACCOUNT NO. DEPT. NO. nATP <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 /> CITY ST ZIP CODE AREA PHONE NO. <br /> MAILING STREET <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 /> PYPROB <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> MT <br /> 3/20/10 <br /> 14270 HAZMAT <br /> CHARGES <br /> LAST - RECIPIENT - FIRST <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 & 2010 HaZmat Fee $170.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $17.00 <br /> vp <br /> TOTAL $236.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> CITY ST ZIP CODE <br /> PRIOR STREET <br /> I <br /> EMPLOYER PHONE NO <br /> EMPLOYER NAME <br /> BETO AUTO REPAIR 209-430-3535 <br /> EMPLOYER STREET <br /> CITY ST ZIPCODE <br /> CA 95205 <br /> 230 N PILGRIM ST STOCKTON <br /> SPBSS€- CO—OWNER <br /> AST <br /> FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <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 STOCKTO <br /> CA 95205 <br /> REPARED BY <br /> CHECKEDB DATE [,/��/�'O coy. zo fs�ae) <br />