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CPG # TO: �-'FICE OF REVENUE AND RECOVERY <br /> . ACCOUNT TRANSMITTAL — o (rr--��LJ(V"Jy <br /> ACCOUNT NO. DEPT. NO. REFERRAL \1111/ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> LODI GRADING & PAVING INC 11 11 <br /> C/O NAME GUARANTOR SSN <br /> MICHAEL R JENNINGS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 9211 E HWY 12 LODI CA 95240 209-369-2930 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5001 E ARMSTRONG RD LODI CA 95240 209-366-2238 <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATE BMCBM INT MONTHLY PAY AMT I PYMT .p'B <br /> 11003 HAZMAT 3/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> non <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> mn <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 6 Chems @ $15.00 Each $90.00 <br /> 10% Late Charge $33.00 <br /> State Service Fee $24.00 <br /> Sm Hz Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $813.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI GRADING & PAVING INC 209-369-2930 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 9211 E HWY 12 LODI CA 95240 <br /> SPOUSE- CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI GRADING & PAVING INC 209-369-2930 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 9211 E HWY 12 LODI CA 95240 <br /> PREPARED BY I CHECKED B JDATE �� COL zo 13iee1 <br />