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CPG # TO: C -CE OF REVENUE AND RECOVERY <br /> TRANSMITTAL ACCOUNT NO. 026000.0 REFERRAL COPY <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CHARLIE'S AUTO PARTS&HARDWARE <br /> C/O NAME GUARANTOR SSN <br /> STANLEY POWERS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO <br /> 4515 E MAIN ST STOCKTON CA 95215 209-466-0841 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 10736 ELKHORN DR STOCKTON CA 95209 209-957-6229 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMI IN MONTHLY PAY AMT <br /> 12030 HAZMAT 3/15/12 <br /> run n�wo <br /> LAST - RECIPIENT - FIRST MI TITLE RIECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE TE: DATE OF <br /> START STOP MED REC NO F CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $270.00 p8q <br /> 1 1 <br /> 30 042 00 0 Hazmat Penalty Fee $27.00 p1q114300P.0 <br /> Pq q42900,0 Sm Hw Gen <5 Tons/yr $213.00 p8q <br /> 1 1 <br /> P84 1 0 290010 Permit Fee Penalty $213.00 p8q <br /> 1 1 <br /> 80 0 290010 State Surcharge Fee $24.00 p8q It 4 00 .0 <br /> 8 11 0 290010 Electronic Surcharge Fee $25.00 p8q P43009.01 <br /> 80 11 0 2 00.p _L �8q P43009.0, <br /> TOTAL $772.00 <br /> PRIOR STREET CITv AT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CHARLIE'S AUTO PARTS& HARDWARE 209-466-0841 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4515 E MAIN ST STOCKTON CA 95215 <br /> ST FIRST MI TITLE SOC SEC NO. I DOB I DR LIC NO AUTO LIC NO <br /> I 1 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CHARLIE'S AUTO PARTS& HARDWARE 209-466-0841 <br /> EMPLOYER STREET CITY �T ZIP CODE <br /> 4515 E MAIN ST STOC ON CA 95215 <br /> CHECKED BY JDATE COL. zo Iaieel <br />