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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL -41 O pyACCOUNT NO. DEPT N REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE - AKA - FIRST MI TITLE <br /> CLEMENTS ROAD WINERY It <br /> C/O NAME GUA;gLAST <br /> JEFF LEBARD <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> CLEMENTS ROAD WINERY P.O. BOX 2818 YOUNTVILLE CA 94599 209-887-3819 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO. <br /> 7415 ST. HELENA HWY YOUNTVILLE CA 94599 209-887-3819 <br /> YM <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM GBM INT MONTHLY PAY AMT <br /> PR <br /> 13302 HAZMAT I 1 11 11 1 1 1 1 1 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 /> 230 026000.0 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR LIG NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CLEMENTS ROAD WINERY 209-887-3819 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 11989N CLEMENTS RD LINDEN CA 95236 <br /> SIPOU49 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 /> CLEMENTS ROAD WINERY 209-887-3819 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 11989 N CLEMEN S R D CA 95236 <br /> REPARED BY CHECKED BY ATE t.fap 3 � COL. 20 (3/BB) <br /> / <br />