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CPG # TO: FICE OF REVENUE AND RECOVERY <br /> It ACCOUNT TRANSMITTAL • COPY RHALL <br /> DEPT. NO. REFERRAL <br /> 026000.0 <br /> - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TO REPAIR LLC <br /> GUARANTOR SSN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1533 S STOCKTON ST LODI CA 95240 <br /> 209-334-2969 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1533 S STOCKTON ST LODI CA 95240 209-334-2969 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PROB <br /> 14236 HAZMAT 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE 9 <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT �CHARGEJ DEPT. NO. S <br /> AMOUNT , <br /> 230 026000.0 2011 Hazmat Fee $115.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $11.50 <br /> i <br /> TOTAL $175.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST I ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DANS TIRE AND AUTO REPAIR LLC 209-334-2969 <br /> EMPLOYER STREET CITY ;CA <br /> ZIP CODE <br /> 1533 S STOCKTON ST LODI 95240 <br /> SPOUSE CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DANS TIRE AND AUTO REPAIR LLC 209-334-2969 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1533 S STOCKTON ST Lp I CA 95240 <br /> 'REPAIRED BY CHECKED BY DATE / coy. zo lareel <br /> o7 7/// <br />