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CPG # TO: rvFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL D <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 v <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> JK AUTOMOTIVE REPAIR <br /> C/O NAME GUARANTOR SSN <br /> DAVID GARZA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 710 E YOSEMITE AVE MANTECA CA 95336-5827 209-825-7340 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 710 E YOSEMITE MANTECA CA 95336 209-825-7340 <br /> USER REFERENCE NO. BILL STAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT PYMT PROB <br /> 9625 HAZMAT 4/15/11 <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 /> -jL <br /> CHARGE Nin DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $100.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $10.00 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee 1 $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $585.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JK AUTOMOTIVE REPAIR 209-825-7340 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 710E YOSEMITE AVE MANTECA CA 95336-5827 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JK AUTOMOTIVE REPAIR 209-825-7340 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 710 E YOSEMITE A E A CA 95336-5827 <br /> PREPARED BY CHECKED BYDATE ��,} 7-/ COL 20 (3/88) <br />