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CPG # TO: --FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL � � �j,� pM <br /> ACCOUNT NO. DEPT. NO. REFERRAL \�\`J/�/) IIILLLIIIIII V <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JIM'S 24 HR GAS 'N GO IIIIIII III III IIIIIII - , <br /> C/O NAME GUARANTOR SSN <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 9320 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 CBM INT MONTHLY PAY AMT PYMT PROBI <br /> 13432 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1.3/15/09 <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 <br /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $10.00 <br /> State Service Fee $24.00 <br /> Sm Hw Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $560.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JIM'S 24 HR GAS 'N GO 925-465-4978 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8203 E 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 <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 /> PREPARED BY I CHECKED BY JDATE 6 / COL. 20 (3M) <br /> o <br />