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"CPG # TO: ICE OF REVENUE AND RECOVERY ir o y <br /> ACCOUNT TRANSMITTAL p <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> HUMBOLDT CREAMERY ASSOCIATION <br /> C/O NAME GUARANTOR SSN <br /> HUMBOLDT CREAMERY ASSOCIATION <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> HUMBOLDT CREAMERY ASSOCIATION 572 HWY 1 FORTUNA CA 95540 (209) 937-9137 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 572 HIGHWAY 1 FORTUNA CA 95540 (707) 725-6182 <br /> PYMT <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT nA PROB <br /> 12471 HAZMAT 3115109 <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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Service Fee $24.00 <br /> Used Oil Only c5 Tons/yr $54.00 <br /> r � <br /> Permit Fee Penalty $54.00 <br /> Addition Of 2 Chems $30.00 <br /> TOTAL 1 $459.00 <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 /> HUMBOLDT CREAMERY ASSOCIATION (209)937-9137 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1270 SHAW RD STOCKTON CA 95215 <br /> SP91114W.- CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> HUMBOLDT CREAMERY ASSOCIATION (209) 937-9137 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1270 SHAW RD STOCKTON CA 95215 <br /> PREPARED BY CHECKED BY ATE COQ. 20 Israel <br /> n <br />