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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL * copy O p�/T <br /> ACCOUNT NO. DEPT. NO. REFERRAL \\1IUU1I(( <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> VALLEY TOWING PRODUCTS <br /> C/O NAME GUARANTOR SSN <br /> RMP TOWING <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> VALLEY TOWING PRODUCTS 1313 S STOCKTON ST LODI CA 95240 209-368-8881 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2250 THUNDERSTICK DR STE 1203 LEXINGTON KY 40505 859-294-5590 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INTI MONTHLY PAY AMT PYMT ROB <br /> 14402 HAZMAT 1.4/1.5/1.1 <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 /> Nn <br /> 230 042000.0 2011 Hazmat Fee $690.00 380 042000.0 Credit Adjustment -$20.00 <br /> 230 042000.0 Hazmat Penalty Fee $69.00 380 042000.0 <br /> 380 042000.0 Gen 50<250 Tons Permit $2149.00 380 042000.0 <br /> 380 01 . .0 Hazardous Waste Pbr $765.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $2894.00 380 002000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> TOTAL $6596.00 <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 /> VALLEY TOWING PRODUCTS 209-368-8881 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1313 STOCKTON ST LODI CA 95240 <br /> CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> VALLEY TOWING PRODUCTS 209-368-8881 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1313 STOCKTON S LODI CA 95240 <br /> REPARED BY CHECKED BY DATE �0?,jr—// COL. M (3/88) <br />