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CPG '# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL Copy <br /> ACCOUNT NO. DEPT. N . <br /> REFERRAL �w <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> V&J ORNAMENTAL IRON WORKS <br /> C/O NAME GUARANTOR SSN <br /> VICTOR RIVARN/JAIME SALAS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1201 N FILBERT ST STOCKTON CA 95205 209-465-3407 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-465-3407 <br /> USER REFERENCE NO. BILL kAT CYCLE ISTATUS DATEI BM CBM INTI MONTHLY PAY AMTJ Y <br /> 13231 HAZMAT 1.3/20/111 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> 1111111111111111111 <br /> 11 <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $285.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 1 1 042000.0 Electronic Surcharge $25.00 <br /> 1 1 042000.0 Hazmat Penalty Fee $28.50 <br /> 380 014 1 .0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> V&J ORNAMENTAL IRON WORKS 209-465-3407- <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1201 N FILBERT ST STOCKTON CA 95205 <br /> S-POUS& CO-OWNER <br /> ST FIRST MI TITLEI SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> V&J ORNAMENTAL IRON WORKS 209-465-3407 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1201 N FILBERT ST STOCF(T CA 95205 <br /> PREPARED BY CHECKED BY ATE /a _/� Coy. 0 cJ <br />