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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> '"WACCOUNT TRANSMITTAL COPY <br /> ..i <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. BILLTAT CYCLE STATUS DATE BMd CBM I:N:Tl MONTHLY PAY AMTYMT PR B <br /> 4649 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 Kin DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $300.00 380 042000.0 <br /> 230 042000.0 Hazmat Penalty Fee $30.00 380 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 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 Payments -$176.00 380 1, 042000.0 <br /> TOTAL $629.00 <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 /> CO—OWNER <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 /> GUARANTEE REPAIR SERVICE 209-339-1100 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 101 COMMERCE ST LODI CA 95240-0845 <br /> REPARED BY ,/ CHECKED BY IRATE <br />