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:.PG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL n PEDD <br /> ACCOUNT NO. DEPT. NO. REFERRAL fi wJ 11!}( <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JIM'S 24 HR GAS 'N GO <br /> C/O NAME GUARANTORISSN <br /> DAISY MAY LLC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> JIM'S 24 HR GAS'N GO 1630 N MAIN ST#320 WALNUT CREEK CA 94596 925-465-4978 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4111 CLARINBRIDGE CIRCLE DUBLIN CA 94568 925-708-7427 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMCI INT MONTHLY PAY AMTP B <br /> 13432 HAZMAT 1.3/20/1,0 <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 Nn DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5 Tons/yr $213.00 Hazmat Penalty Fee $27.00 <br /> 2010 Hazmat Fee $270.00 Permit Fee Penalty $1013.00 <br /> Ust State Surcharge Fee $45.00 <br /> Additional Ust $250.00 <br /> Ust Facility & 1 Tank $550.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> TOTAL $2417.00 <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 /> JIM'S 24 HR GAS 'N GO 925-465-4978 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8203E HWY 26 STOCKTON CA 95215 <br /> SPOUSE- CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JIM'S 24 HR GAS 'N GO 925-465-4978 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8203 E HWY 26 STOC TON CA 95215 <br /> PREPARED BY I CHECKED BY JDATE 9 COL. 20 (areal <br />