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'CPG #' TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL Copy ACCOUNT NO. REFERRAL <br /> DEPT. NO. <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JOHN ROSSI HAY CO <br /> C/O NAME GUARANTOR SSN <br /> JOHN ROSSI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> JOHN ROSSI HAY CO P.O. BOX 332 MANTECA CA 95336 209-823-3965 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 332 MANTECA CA 95336 209-823-3965 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT P MT B <br /> 5977 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 /> CHhinARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $315.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $31.50 380 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 $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $821.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY STZIP CODE <br /> EMPLOYER NAME <br /> EMPLOYER PHONE NO <br /> JOHN ROSSI HAY CO 209-823-3965 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AIRPORT WAY MANTECA CA 95336 <br /> CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME <br /> EMPLOYER PHONE NO <br /> JOHN ROSSI HAY CO 209-823-3965 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AIRPORT W Y . TE CA 1 95336 <br /> REPARED BYCHECKED BY DATE �7 �� COL 20 (3/88) <br />