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CPG # • TO: ' ,ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> C: oFly <br /> 026000.0 <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 TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT PYMT PROB <br /> 9625 HAZMAT 11/15/09 <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 /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2007 - 2009 Hmmp <br /> Annual Fee $210.00 <br /> 2 Chems @ $15.00 <br /> Each Year $90.00 <br /> 10% Late Charge $30.00 <br /> Sm Hz Gen <5 Tons/yr $213.00 <br /> State Surchage $24.00 <br /> TOTAL $567.00 <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 /> S-gA�FST� CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I I I I I I I I I I f:dl I I I I <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 AVE M4NTEPCA 95336-5827 <br /> PREPARED B CHECKED BY DATE ( /0 COL. 20 (3/88) <br /> 1 <br />