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CPG,# TO: OFFICE OF REVENUE AND RECOVERY <br /> Ak ACCOUNT TRANSMITTAL .C ( p <br /> ACCOUNT NO. DEPT. NO. REFERRAL D <br /> E026000.0 <br /> LAST GUARANTOR FIRST MI TITLE LAST AKA - FIRST MI TITLE <br /> QUINTERO'S Q-LUBE&TUNE 1 17-1 <br /> CIO NAME GUARANTOR SSN <br /> CESAR QUINTERO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2521 N WEST LN STOCKTON CA 95205 209-948-1452 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1502 VENICE STOCKTON CA 95206 209-948-1452 <br /> USER REFERENCE NO. BILL 3TAT CYCLE STATUS DATE BM CBMJ INTI MONTHLY PAY AMT n,PYMT PROB <br /> 12048 HAZMAT 3120110 <br /> CHARGES <br /> LAST RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HAIM&MCSDESCRIPTION AMOUNT <br /> Kin <br /> 230 026000.0 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $100.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 t g'tl <br /> Hazmat Penalty Fee $10.00 <br /> Permit Fee Penalty $213.00 <br /> }b TOTAL I j d $5 g` 0 <br /> GUARANTOR LN IV ' <br /> DOB DR LIC NO AUTO LIC NO Y <br /> I t& -_ <br /> PRIOR STREET CITY ST <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> QUINTERO'S Q-LUBE&TUNE 209-948-1452 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2521 N WEST LN STOCKTON CA 95205 <br /> SPAT�S9 CO-OWNER <br /> AST FIRST Ml TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> -7 1 1 1 [: I I I I I I I I I I <br /> I 1 I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> QUINTERO'S Q-LUBE&TUNE 209-948-1452 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2521 N WEST LN ST CA 95205 <br /> REPARED BY CHECKED BY DATE `f /a COL. 11 (3188} <br />