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CPG # TO: OE OF REVENUE AND RECOVERY <br /> F C <br /> 0 ACCOUNT TRANSMITTAL • COPYACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ROCKY'S RESTAURANT <br /> C/O NAME GUARANTOR SSN <br /> BARRY BENIGNO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ROCKY'S RESTAURANT P.O. BOX 2601 LODI CA 95241 209-369-1973 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1121 W CHURCHILL ST STOCKTON CA 95207 <br /> USER REFERENCE NO. IBILL kTAT ICYCLE ISTATUS DATEI BM CBM IN MONTHLY PAY AMT rc <br /> 9760 HAZMAT <br /> 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECff= USER REFERENCE NO/NARRATIVE <br /> SE IC DATE: DATE OF <br /> STAR STOP MED REC NO CHARGE <br /> C&230042000.0 <br /> EPT. NO. DESCRIPTION AMOUNT a_ , <br /> DEPT.NO. DESCRIPTION AMOUNT <br /> 2012 Hazmat Fee $85.00 4 00 .0042 00 0 Hazmat Penalty Fee $8.50 4 00 .042 00 0_jI State Surcharge Fee $24.00 4 00 .08 0 2 000 Electronic Surcharge Fee $25.00q , P43009.0 <br /> 80 1 0 2 00 0 I R8q4 00 .0 <br /> 60 1 0I42q0010 1 p8q <br /> 80 0 2qOO.p I P894 00 .0 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROCKY'S RESTAURANT 209-369-1973 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 14659 N THORNTON RD LODI CA 95242 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROCKY'S RESTAURANT 209-369-1973 <br /> EMPLOYER STREET <br /> 14659 N THORNTON RD LO I CA 1 95242 <br /> CHECKED BY. DAT COL. 90 PAR) <br />