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CPQ" TO: *.,'FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERI l <br /> 026000.0 1 <br /> RAL <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JERRY JOY CONCRETE <br /> C/O NAME GUARANTOR SSN <br /> COLLEEN JOY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> JERRY JOY CONCRETE 3028 CANAL DR STOCKTON CA 95204 209-462-1481 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3028 CANAL DRIVE STOCKTON CA 95204 209-462-1481 <br /> USER REFERENCE NO. I BILL STd CYCLE STATUS DATEI BMd CBMC INT MONTHLY PAY AMT <br /> 12088 HAZMAT I I I I I I I I I I I I I I j 3/15/08 <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 /> L230 <br /> DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 7 Chems @ $15.00 Each $105.00 <br /> 10% Late Charge $34.50 <br /> State Surcharge Fee $24.00 <br /> TOTAL $403.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JERRY JOY CONCRETE 209-462-1481 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4900 E MARIPOSA RD STE C STOCKTON CA 95215 <br /> SiN)UeB CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JERRY JOY CONCRETE 209-462-1481 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4900 E MARIPOSA RD STE C STOCKTON CA 95215 <br /> PREPARED BY(SaS 1dI CHECKED BY I DATE (/ /P 1 COL. 20 (N68 <br />