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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL C <br /> py <br /> ACCOUNT NO. DEPT. NO REFERRAL `� O026000.0 <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 TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT TpphAnATr <br /> B <br /> 13231 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> MOO <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> mr)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 LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <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 /> SP446 o- CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. 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 STOCKTO CA 95205 <br /> REPARED BY I CHECKED BY JDATE ,L/ 3 0 1 COL. 20 (3W) <br />