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CPG # TO: ICE OF REVENUE AND RECOVERY • <br /> ACCOUNT TRANSMITTAL � <br /> ACCOUNT NO. DEPT.NO. REFERRAL V <br /> 026000.0 ATFt C LJ <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 BILL STA CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> DA RM DATE <br /> 2876 HAZMAT 3/15/07 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2007 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 $206.00 <br /> Permit Fee Penalty $206.00 <br /> TOTAL $782.50 <br /> GUARANTOR <br /> DOB DR 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 1 95253 <br /> 9FeHeR CO-OWNER <br /> LAST FIRST MI TITLEJ 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 Bl( I CHECKED BY L��" DATE 6 O 1 COL. 20 (3/88 <br />