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CPG"# TO: OFF CE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT,NO. REFERRAL c <br /> O P 026000.0 lu( <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> B AND G TRUCK WASH <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 209-341-9870 <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 BM CBM INT MONTHLY PAY,!M r <br /> 12445 HAZMAT <br /> 3/.5/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVIr.CE DATE• DATE OF <br /> START STOP MED RED NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $270.00 p8q4 300p.01 <br /> 30 1 014290010 Hazmat Penalty Fee $27.00 p1q1143019.01 <br /> p8q I q42900,0 State Surcharge Fee $24.00 p8q4 00 .0 <br /> p8q I 0I42q0010 Electronic Surcharge Fee $25.00 p8Q 4 00 .0 <br /> 80 0 2 00 0 I 4 00 .0 <br /> 80 1 014290010 p8q 4 00 .0 <br /> 80 1 0I42q00.p I p8q P4 00 .0 <br /> TOTAL $346.00 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BAND G TRUCK WASH 209-341-9870 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 816 HWY 99 FRONTAGE RD RIPON CA 95366 <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BAND G TRUCK WASH 209-341-9870 <br /> EMPLOYER STREET <br /> 816 HWY 99 FRONTAGE RDI N CA 95366 <br /> JDATE COL. 20 (3188) <br />