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CPG # TO: r ICE OF REVENUE AND RECOVERY <br /> ... ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST MI TITLE <br /> HERNANDEZ AUTO PAINT <br /> C/O NAME GUARANTOR SSN <br /> ANTONIO HERNANDEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> HERNANDEZ AUTO PAINT 840 E JEFFERSON ST STOCKTON CA 95206 209-423-1977 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8923 EUREKA STOCKTON CA 95210 209-981-6956 <br /> MT B <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> 13927 HAZMAT 7/15/09 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2008& 2009 Annual <br /> Hmmp Fee $480.00 <br /> 1 Chem @ $15.00 <br /> Each Year $30.00 <br /> 10% Late Charge $51.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $585.00 <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 /> HERNANDEZ AUTO PAINT 209-423-1977 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 840 E JEFFERSON ST STOCKTON CA 95206 <br /> S-PAUFS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> HERNANDEZ AUTO PAINT 209-423-1977 <br /> EMPLOYER STREET CITY , ST ZIP CODE <br /> 840 E JEFFERSON ST STOCKTON Z�Q CA 95206 <br /> REPARED BY CHECKED BY ATE COL. z0(SIB9) <br /> t <br />