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CPG # TO: ^FICE OF REVENUE AND RECOVERY COPY ACCOUNT TRANSMITTAL ACCOUNT NO. DEPT. NOREFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BAND G TRUCK WASH 1 11 1 LL--� I . . I I . I I <br /> C/O NAME GUARANTOR SSN <br /> AMARJIT SINGH <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> B AND G TRUCK WASH 2904 CANYON DR MODESTO CA 95351 209-495-0544 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2904 CANYON DR MODESTO CA 95351 209-495-0544 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMCBMC INT MONTHLY PAY AMT n, <br /> PYMT PROB <br /> 12445 HAZMAT 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTQQU USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2011 Hazmat Fee $270.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $27.00 <br /> TOTAL $346.00 <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 /> BAND G TRUCK WASH 209-495-0544 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 816 HWY 99 FRONTAGE RD RIPON CA 95366 <br /> S1?GLWk& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BAND G TRUCK WASH 209-495-0544 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 816 HWY 99 FRONTAGE RD ,;EN N CA 95366 <br /> REPAREDBY CHECKED BY DATE ..5j3 _/'/ COL. 20131881 <br />