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CPG # TO: OE 'E OF REVENGE AND RECOVERY COPY <br /> TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <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 BMd CBMd INd MONTHLY PAY AMT <br /> 5977 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT 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 /> NF) W9 <br /> 230 042000.0 2012 Hazmat Fee $315.00 89 1 P43009.01 I Permit Penalty $675.00 <br /> 30 014290010 1 Hazmat Penalty Fee $31.50 p1q104300P.01 <br /> p8q I q429OOrO I Sm Hw Gen <5 Tons/yr $213.00 p8q <br /> 1 1 <br /> pog 0 2 00 0 Permit Fee Penalty $213.00 Pq 1 4 00 .0 <br /> 8 0 2 00 0 State Surcharge Fee $24.00 8q 1 P43009.01 <br /> 80 0 2 00 o I Electronic Surcharge Fee $25.00 8 4 3009.01 <br /> 80 1 OlS2900.2 Ast Fac 10k- <=100k Gal $675.00 p8q <br /> 1 1 <br /> TOTAL $2171.50 <br /> PRIOR STREET riTy ST ZIP CODE <br /> I <br /> EMPLOYER NAME 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 /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JOHN ROSSI HAY CO 209-823-3965 <br /> EMPLOYERSTREET CITY ST 71P ConP <br /> 511 N AIRPORT WA A T� CA 95336 <br /> 1, CHECKED BY JDATE ,I COL. zo Iaieel <br />