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CPG TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> OPY ACCOUNTNO. DEPT.NO. REFERRAL <br /> .... C <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> FOREST LAKE GOLF COURSE (CLOSED) <br /> C/O NAME GUARANTOR SSN <br /> MARGARET J RING <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 209-369-5457 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 209-369-7464 <br /> USER REFERENCE NO. BILL TAT 11CYCLE STATUS DATE1 BMd CBMd IN MONTHLY PAY AMT I UB <br /> 5689 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> ITT <br /> SERVICE DATE: DATE OF <br /> TA T STOP MED RE C NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> pip fdf) <br /> 230 042000.0 2012 Hazmat Fee $315.00 8q 1 P43009.01 <br /> 30 1 042 00 0 Hazmat Penalty Fee $31.50 P89 P4300?.O <br /> 8 42 Oo o I State Surcharge Fee $24.00 R8q P44009.0, <br /> Pq 1 0II42q00j0 Electronic Surcharge Fee $25.00 p8q P43009.01 <br /> 80 11 01,112 0010 1 1 I318q4 00 .0 <br /> 80 1, 0 290010 8 4 00 .0 <br /> 80 11 0I42q00.P8 4 00 .0 <br /> TOTAL 1 $395.50 <br /> GUARANTOR <br /> I III III <br /> PRIOR STREET r.1 qT ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FOREST LAKE GOLF COURSE (CLOSED) 209-369-5457 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FOREST LAKE GOLF COURSE (CLOSED) 209-369-5457 <br /> EMPLOYER STREET CITY qI 71P cnnF= <br /> 2450 E WOODSON RD (CAMP CA 95220-9646 <br /> ' CHECKED By D COL 20 la�9e1 <br />