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CPG- 4 TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL O �� <br /> Y REFERRAL <br /> ACCOUNT NO. DEPT.NO. <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> NORTH RIVER MILLWORK <br /> C/O NAME GUARANTOR SSN <br /> WILLIAM HUBER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> NORTH RIVER MILLWORK P.O. BOX 5864 AUBURN CA 95604 530-305-7660 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PO BOX 5864 AUBURN CA 95604 530-305-7660 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT <br /> 14597 HAZMAT 1. 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO, DESCRIPTION AMOUNT <br /> NR Nf� <br /> 230 042000.0 2012 Hazmat Fee $300.00 p8q P43009.0, <br /> 30 1 014290010 Hazmat Penalty Fee $30.00 38q Oa 00 .0 <br /> �8q I q429OOrO I State Surcharge Fee $24.00 38q <br /> 1 1 <br /> pq 0 2 00 0 Electronic Surcharge $25.00 P89 <br /> 1 1 <br /> 80 0 2 000 I p8q <br /> 1 1 <br /> 80 1 0 2 00 0 , 1 P89 1, P43009.0, <br /> 80 1 0 2qOO.p I p8q4 00 .0 <br /> TOTAL $379.00 <br /> GUARANTOR <br /> PRIOR STREET CITY AT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> NORTH RIVER MILLWORK 530-305-7660 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 735 S SUTTER ST STOCKTON CA 95203 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 1 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> NORTH RIVER MILLWORK 530-305-7660 <br /> EMPLOYERSTREET CITY "IT 71P CODF <br /> 735 S SUTTER ST STOC 0 CA 95203 <br /> r i <br /> U CHECKED BY JDATE Ca. 20 (3183) <br />