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;PG• TO: C CE OF REVENUE AND RECOVERY REFERRAL �J D <br /> TRANSMITTAL c 0 p 'I <br /> ACCOUNT NO. DEPT.NO. <br /> 026000.0 <br /> LAST - AKA - FIRST MI TITLE <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> BIG O TIRES#31 GUARANTOR SSN <br /> C/O NAME <br /> EUGENE CHRISTENSEN <br /> CITY ST ZIP CODE AREA PHONE NO. <br /> MAILING STREET 209-612-1252 <br /> 810 E YOSEMITE AVE MANTECA CA 95336 <br /> CITY ST ZIP CODE AREA PHONE NO. <br /> RESIDENCE STREET <br /> RIPON CA 95366 209-612-1252 <br /> 607 PALM AVE <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 3/15/12 <br /> 1136 HAZMAT <br /> - <br /> MI TITLE CIPIENT USER REFERENCE NOINARRATIVE <br /> LAST - RECIPIENT FIRST <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.No. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Ha mat Fee $85.00 8 <br /> 400 .0 <br /> 30 oat 00 o Hazmat Penalty Fee $8.50 8 04 00 .0 <br /> g 42 00 o Sm Hw Gen <5 Tons/yr $213.00 8 <br /> 4 00 .0 <br /> g 0 2 000 Permit Fee Penalty $213.00 8 <br /> a 00 .0 <br /> 80 0 2 000 State Surcharge Fee $24.00 8 4 00 .0 <br /> ao 0 2 00o Electronic Surcharge Fee $25.00 8 <br /> 400 .0 <br /> g 4 00 .0 <br /> 80 0 2 00. TOTAL $568.50 <br /> ZIP CODE <br /> PRIOR STREET <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> 2 <br /> BIG O TIRES#31 209-612-125 <br /> CITY ST ZIP CODE <br /> EMPLOYER STREET <br /> CA 95336 <br /> 810E YOSEMITE AVE MANTECA <br /> ST <br /> FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER PHONE NO <br /> EMPLOYER NAME 209-612-1252 <br /> BIG O TIRES#31 <br /> EMPLOYER STREET CA 95336 <br /> 810E YOSEMITE AVE MANT W A DATE ,I coL. zo iaiae) <br /> 1PRFPARET)B4 / ,1 CHECKED BY <br />