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CPG�g TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> REFERRAL Fly ACCOUNT NO. DEPT. NO. O <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> EDDIE BANDINI & SONS INC <br /> C/O NAME GUARANTOR SSN <br /> EDDIE BANDINI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> EDDIE BANDINI &SONS INC P.O. BOX 253 FARMINGTON CA 95230-0253 209-463-5516 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 19721 LITTLE JOHN RD. STOCKTON CA 95215 209-463-5516 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBM IN MONTHLY PAY AMT <br /> 10053 HAZMAT 1. 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $255.00 p8q <br /> 30 1 014290010 1 Hazmat Penalty Fee $25.50 p8q1043009.01 <br /> �8q I q429OOrO I State Surcharge Fee $24.00 p8q4 00 .o <br /> p8q 0 2 0010 1 Electronic Surcharge Fee $25.00 psq <br /> 80 1 0 2 00 0 1 p8Qa 00 .0 <br /> 80 1 0 2 00 0 I p8q <br /> 60 1 0I12q00.p8 1 P43009.01 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> PRIOR STREET qT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EDDIE BANDINI & SONS INC 209-463-5516 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2201 W WASHINGTON ST BOX 4 STOCKTON CA 95203 <br /> AST FIRST MI TITLE1 SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EDDIE BANDINI & SONS INC 209-463-5516 <br /> EMPLOYER STREET <br /> 2201W WASHINGTON S BO STOCKTON CA 1 95203 <br /> EC ED BY IDATE COL. 20 (3I58) <br />