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CPG # T0: ICE REVENUE AND RECOVERY COPY ACCC 10OUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TED'S WELDING & REPAIR <br /> C/O NAME GUARANTOR SSN <br /> BILL(GEORGE) BRAUN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TED'S WELDING & REPAIR P.O. BOX 726 VICTOR CA 95253 209-368-9864 OR <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 611 VICTOR CA 95253 209-365-9416 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT YMT PR <br /> OB <br /> 2876 HAZMAT 1.3/1 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Nn 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $28.50 <br /> State Service Fee $24.00 <br /> Sm Hw Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $763.50 <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 /> TED'S WELDING & REPAIR 209-368-9864 OR 209 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8932 E HWY 12 VICTOR CA 95253 <br /> SPAUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TED'S WELDING & REPAIR 209-368-9864 OR 209 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8932 E HWY 12 VICTOR CA 95253 <br /> REPARED BY 1 CHECKED BY JDATE COL 20(area) <br />