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CPG #, T0: `'ICE OF REVENUE AND RECOVERY 1../ C <br /> OPY <br /> ACCOUNT TRANSMITTAL nATP <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GUARANTEE REPAIR SERVICE <br /> C/O NAME GUARANTOR SSN <br /> BONNIE BERNEISER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> GUARANTEE REPAIR SERVICE P.O. BOX 246 VICTOR CA 95253-0246 209-339-1100 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 12611 E PELTIER RD ACAMPO CA 95220 209-369-8373 <br /> USER REFERENCE NO. I BILL STAd CYCLE STATUS DATE BM CBMC INT I MONTHLY PAY AMT <br /> nj IF DATE I TERM DATE <br /> 4649 HAZMAT 3/15/07 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE <br /> NO DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2007 Hmmp Annual Fee $240.00 <br /> 5 Chems @ $15.00 Each $75.00 <br /> 10% Late Charge $31.50 <br /> State Service Fee $24.00 <br /> Sm Hz Gen <5 Tons/yr $206.00 <br /> Permit Fee Penalty 1 $206.00 <br /> TOTAL $782.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GUARANTEE REPAIR SERVICE 209-339-1100 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 101 COMMERCE ST LODI CA 95240-0845 <br /> SPOUSE CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GUARANTEE REPAIR SERVICE 209-339-1100 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 101 COMMERCE ST LODI CA 95240-0845 <br /> PREPARED B1 CHECKED BY DATE d-7 Coy. 20 IM, <br /> c�e_ <br />