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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL O FlyACCOUNT NO. DEPT. NO. <br /> REFERRAL �../ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> OFF ROAD ENTERPRISES <br /> C/O NAME GUARANTOR SSN <br /> WADE MARTIN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2953 CHERRYLAND AVE #BSTOCKTON CA 95215-2233 209-931-1170 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO. <br /> 3261 CHERRYLAND AVE. STOCKTON CA 95215 (209)969-7178 <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATEI BMC1 C6MC1 INTI MONTHLY PAY AMT <br /> 6985 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1.4/1 <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 042000.0 2011 Hazmat Fee $285.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $28.50 380 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 $788.50 <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 /> OFF ROAD ENTERPRISES 209-931-1170 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2953 CHERRYLAND AVE#B STOCKTON CA 95215-2233 <br /> CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> OFF ROAD ENTERPRISES 209-931-1170 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2953 CHERRYLAND AVE#B SS CKTON I _ CA 95215-2233 <br /> PREPAREDBY ICHECKEDBY DATE 7�A f7 COL. n (3ft) <br />