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SPG 4# r TO: 0 E OF REVENUE AND RECOVERY <br /> y ) MTM TRANSMITTAL D <br /> ACCOUNT NO. DEPT.NO. REFERRAL O p U <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> AD FORCE PRIVATE SECURITY <br /> C/O NAME GUARANTOR SSN <br /> GEORGE GARCIA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> AD FORCE PRIVATE SECURITY P.O. BOX 55331 STOCKTON CA 95205 209-462-7600 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO <br /> 5342 LA MIRADA WY STOCKTON CA 95212 209-462-8420 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBM IN MONTHLY PAY AMT <br /> 12268 HAZMAT 3/15/12 RA4 DATE <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATI1-4 <br /> VE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT ICHARGE DEPT.N0. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $115.00 4 00 .01 1 <br /> 30 042 00o Hazmat Penalty Fee $11.50 04 00 .os 42 00o Sm Hw Gen <5 Tons/yr $213.00 4 00 .o8 0 2 00o Permit Fee Penalty $213.00 1 P43009.01 <br /> 8 0 2 o0 0 I State Surcharge Fee 1 $24.00 1 p8Q4 009.01 <br /> s 04290010 Electronic Surcharge Fee $25.00s 4 009.01 <br /> ?Bq 0200. 89 1 P43009.01 <br /> TOTAL 1 $601.50 <br /> PRIOR STREET ri qT ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AD FORCE PRIVATE SECURITY 209-462-7600 <br /> EMPLOYERSTREET CITY ST ZIPCODE <br /> 1625 N REPORT AVE STOCKTON CA 1 95205 <br /> ST FIRST MI TITLEJ SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AD FORCE PRIVATE SECURITY 209-462-7600 <br /> EMPLOYERSTREET CITY S <br /> 1625 N REPORT AVE S CKT N CA 95205 <br /> IDATE COQ. 20 (wse) <br />