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CPG # TO: fo TCE OF REVENUE AND RECOVERY • <br /> ACCOUNT TRANSMITTAL <br /> CO <br /> nACCOUNTNO. EPT.NO. REFERRAL DATE <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. I BILLI STAI CYCLEI STATUS DATEI BM CBM( INT MONTHLY PAY AMT nt IF DATE TERM DATE <br /> 2876 HAZMAT I I I L3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT I USER REFERENCE NO/NARRATIVE <br /> noR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONn <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 5 Chems @ $15.00 Each $75.00 <br /> 10% Late Charge $31.50 <br /> State Service Fee $24.00 <br /> Sm Hw Gen <5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $796.50 <br /> GUARANTOR <br /> DOB OR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY sT ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TED'S WELDING&REPAIR 209-368-9864 OR <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8932 E HWY 12 VICTOR CA 95253 <br /> 9RAH9E CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TED'S WELDING&REPAIR 209-368-9864 OR <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8932 E HWY 12 VICTOR CA 95253 <br /> PREPARED BY/- I CHECKED BY - DATE .,/ �),y coy. 20 (3M <br />