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CPG # TO: O' .�E OF REVENUE AND RECOVERY <br /> 3kr'rnTMrri <br /> TRANSMITTAL <br /> ACCOUNT NO. DEPT.No. COPY <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> MIRACLE MILE DRY CLEANERS <br /> C/O NAME GUARANTOR SSN <br /> WILTON FAMILY LLC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> MIRACLE MILE DRY CLEANERS P.O. BOX 692163 STOCKTON CA 95269-2163 209-464-0411 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 692163 STOCKTON CA 95269-2163 209-481-2414 <br /> USER REFERENCE NO. I BILL kTAT ICYCLE ISTATUS DATEI BM d CBM d INMONTHLY PAY AMT n,'=ynMA'TP PHL) <br /> . nAZF- <br /> 6115 HAZMAT 3/15/12 <br /> '--N— <br /> LAST - RECIPIENT FIRST MI TITLE ECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGEI DEPT.NO. DESCRIPTION AMOUNT <br /> PjA .1 1 <br /> 230 042000.0 2012 Hazmat Fee $255.00 8 4 009.01 1 <br /> ?30J 1 014290011 1 Hazmat Penalty Fee $25.50 P89 04300P.0 1 1 <br /> p8q I q42900r0 Sm Hw Gen <5 Tons/yr $213.00 p8q P4;009.01 1 <br /> p8q 0,42Q00,0 Permit Fee Penalty $213.00 p8q 1 P43009.01 1 <br /> ?8q 0I42q0010 State Surcharge Fee $24.00 1 p8q 1 P43009.0, <br /> ?81) 1 0I42q0010 Electronic Surcharge Fee $25.00 p8q 1 P43009.01 1 <br /> ?801 1 002400-P 1 p8q 1 P43009.01 1 <br /> TOTAL $755.50 <br /> DOR DR I Ir,NO Al]TO I ICNO <br /> PRIOR STREET rlTy ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> MIRACLE MILE DRY CLEANERS 209-464-0411 <br /> EMPLOYER STREET CITY ST r---ZIP cop <br /> 82 W CASTLE ST STOCKTON CA 1 95204 <br /> AST FIRST MI TITLEI SOC SEC NO. DOB I DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MIRACLE MILE DRY CLEANERS 209-464-0411 <br /> EMPLOYER STREET CITY -OnF <br /> IP <br /> 82 W CASTLE ST T C O CA 95204 <br /> PRFPARFn RY CHECKED BY IDATE COL. 20(3M) <br />