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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL �n/J <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SUPER SMOG & REPAIR <br /> C/O NAME GUARANTOR SSN <br /> ROBERT VASQUEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 511 N AMERICAN ST STOCKTON CA 95202 916-261-5094 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO. <br /> 849 SHELLWOOD WAY SACRAMENTO CA 95831 916-261-5094 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I PYMT I PROS <br /> 13397 HAZMAT 3/20/10 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Nn <br /> 230 026000.0 Sm Hw Gen<5tons/yr $213.00 <br /> 2010 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $568.50 <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 /> SUPER SMOG & REPAIR 916-261-5094 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 511 N AMERICAN ST STOCKTON CA 95202 <br /> SBAHS� CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> ----------------- <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SUPER SMOG& REPAIR 916-261-5094 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AMERICAN STSCA 95202 <br /> REPARED BY CHECKED BV ATE -] �p COL. 20 11 <br />