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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. N REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> STOCKTON SERVICE STATION EQUIP <br /> C/O NAME GUARANTOR SSN <br /> MARK HENDERSON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> STOCKTON SERVICE STATION EQUIP CO INC P.O. BOX 508 STOCKTON CA 95201 209-464-8333 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 7513 ROSEWOOD STOCKTON CA 95207 209.478-0482 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I nj T PR <br /> IF:YM <br /> 4957 HAZMAT 3/20/10 <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 /> 230 026000.0 Sm Hw Gen<5tons/yr $213.00 <br /> 2010 Hazmat Fee $300.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $30.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $805.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> STOCKTON SERVICE STATION EQUIP CO INC 209-464-8333 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 808 N UNION ST STOCKTON CA 95205 <br /> Sp9iJSE. CO—OWNER <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 /> STOCKTON SERVICE STATION EQUIP CO INC 209-464-8333 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 808 N UNION ST TOC ON CA 95205 <br /> PREPARED BY CHECKED BY DATE > a S--rO COL 20(3M) <br />