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CPG # TO: OF' CE OF REVENUE AND RECOVERY COPY ACCOUNT TRANSMITTALACCOUNT NO. DEPT. NO. REFRRAL 026000.0 LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE CANCUN RESTAURANT C/O NAME GUARANTOR SSN JUAN RUVALCARA MAILING STREET CITY ST ZIP CODE AREA PHONE NO. CANCUN RESTAURANT 135 E MINER AVE STOCKTON CA 95202 (209)607-0571 RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. 1404 N MONROE ST STOCKTON, CAQ 95203 (209)607 0571 USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT ni PY PROB 14234 HAZMAT 1j 11 11 1 1 1 1 1 1 1 1 1 1.6/1.5/1.0 CHARGES LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE 11111 SERVICE DATE: DATE OF START STOP MED REC NO CHARGE CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT.NO. DESCRIPTION AMOUNT 230 026000.0 2005-2010 Hazmat Fee $1530.00 State Surcharge Fee $24.00 Electronic Surcharge Fee $25.00 Payments -$591.50 Hazmat Penalty Fee $98.75 WIN TOTAL $1086.25 GUARANTOR DOB DR LIC NO AUTO LIC NO PRIOR STREET CITY ST ZIP CODE EMPLOYER NAME EMPLOYER PHONE NO CANCUN RESTAURANT (209)607-0571 EMPLOYER STREET CITY ST ZIP CODE 135 E MINER AVE STOCKTON CA 95202 SPOUSE CO—OWNER AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO I I I EMPLOYER NAME EMPLOYER PHONE NO CANCUN RESTAURANT (209)607-0571 EMPLOYER STREET CITY ST ZIP CODE 135 E MINER AVE STO KTO CA 95202 PREPARED BY CHECKED BY DATE p� ac! (� COL. 20 (3/8B)