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CPG # TO: FICE OF REVENUE AND RECOVERY <br /> 46 ACCOUNT TRANSMITTAL . O pyACCOUNT NO. DEPT. NO. REFERRAL026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> D.A. ARCHER EXCAVATING <br /> C/O NAME GUARANTOR SSN <br /> DAVID A ARCHER JR <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> D.A. ARCHER EXCAVATING 5948 E WATERLOO RD STOCKTON CA 95215 209-601-3745 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5948 E. WATERLOO ROAD STOCKTON CA 95215 209.601-3745 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMINT MONTHLY PAY AMT P MT PR <br /> OB <br /> 13269 HAZMAT 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT HARGE DEPT.NO. DESCRIPTION AMOUNT <br /> mn <br /> 230 026000.0 2011 Hazmat Fee $345.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $34.50 SSW <br /> TOTAL $428.50 <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 /> D.A. ARCHER EXCAVATING 209-601-3745 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 775 SECOND ST STOCKTON CA 95206 <br /> SPOUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB I DR LICNO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D.A.ARCHER EXCAVATING 209-601-3745 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 775 SECOND ST STOCKTON �- CA 95206 <br /> PREPARED BY CHECKED BY DATE dI—.,? , `/ 1 coy. 20 laieel <br />