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CPG # TO: ICE OF REVENUE AND RECOVERY opy ACCOUNT TRANSMITTAL �ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> COALCOMAN AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> JORGE DIAZ JR/RUBEN GARCIA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1042 S SINCLAIR AVE STOCKTON CA 95215 209-603-2161 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5262 E ARDELLE AVE. STOCKTON CA 95215 209-603-2161 <br /> USER REFERENCE NO. I BILL TAT CYCLE STATUS DATE BMCBM INT MONTHLY PAY AMT P,TMT PROB <br /> 13160 HAZMAT 3/15/09 <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 /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $10.00 -.'t.'',=': <br /> LU Taw <br /> State Surcharge Fee $24.00 r ' <br /> Sm Hw Gen <5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> y� <br /> TOTAL $560.00 <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 /> COALCOMAN AUTO REPAIR 209-603-2161 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1042 S SINCLAIR AVE STOCKTON CA 95215 <br /> S-PAHS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LICNO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> COALCOMAN AUTO REPAIR 209-603-2161 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1042 S SINCLAIR AVE STOCKTON CA ?2219 <br /> PREPARED BY CHECKED BY JDATE .�o , p COL. 20 13M) <br /> u / <br />