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CPG # TO: BICE OF REVENUE AND RECOVERY <br /> 1� C O py <br /> ACCOUNT TRANSMITTAL �./ <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> R&R MCCULLOUGH MOBILE REPAIR <br /> C/O NAME GUARANTOR SSN <br /> RANDY MCCULLOUGH <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> R&R MCCULLOUGH MOBILE REPAIR 177 S KELLY ST LODI CA 95240 209-334-4305 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 80 ALMO GALT CA 95632 209-334-4305 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BlACBM INT MONTHLY PAY AMT PYM PROB <br /> 12929 HAZMAT I I I I I I I I I 1 13/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> ki,230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $28.50l% <br /> State Service Fee $24.00 <br /> Sm Hz Gen <5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $763.50 <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 /> R&R MCCULLOUGH MOBILE REPAIR 209-334-4305 <br /> EMPLOYER STREET CITY I ST ZIP CODE <br /> 177 KELLY ST LODI CA 95240-3107 <br /> SPOUS& CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> R&R MCCULLOUGH MOBILE REPAIR 209-334-4305 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 177 KELLY ST LODI CA 95240-3107 <br /> PREPARED BY CHECKED BY DATE �� �� COL. X(3RB) <br />