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CPG m TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY ACCOUNT NO, DEPT.NO. REFERRAL 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PCI-PAINTING <br /> CIO NAME GUARANTOR ni <br /> PCI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO <br /> 620 SAN JUAN AVE STOCKTON CA 95203 . 209-460-0498 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 SAN JUAN AVE STOCKTON CA 95203 209-460-0498 <br /> PYMT <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMC1 CBMC1 INTIMONTHLY PAY AMT <br /> 13313 HAZMATJ 3/15112 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> 5 RVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> pip rdf) <br /> 230 042000.0 2012 Hazmat Fee $255.00 8q 1 P4;002.0 <br /> 30 1 014291110 1 Hazmat Penalty Fee $25.50 p8qP43009.01 <br /> �8q I q42900fO I State Surcharge Fee $24.00 p8q <br /> 1 1 <br /> p8q 1 0 2 00 0 Electronic Surcharge $25.00 p8q <br /> $0 I 0 2 OO 0 p8q4 00 .0 <br /> 1 0 220010 8P43009-01 <br /> $0 1 0 2q()Op p8q2 ()O4 00 .a <br /> TOTAL $329.50 <br /> GUARANTOR <br /> DOB DR I Ir KjQ At ITO I Ir NO <br /> -1 1 11 oil 1111. 111 11'�Ip <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 SAN JUAN AVE STOCKTON CA 195203 <br /> AST FIRST MI TITLE SOC SEC NO. DOS DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET CITY 71P CODE <br /> 620 SANJUAN AVE STOCKTO CA 95203 <br /> FT)RVPRE12AIR /� CHECKED B DATE cap. 20 131587 <br />