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CPG # TO: ICE OF REVENUE AND RECOVERY <br /> ff ACCOUNT TRANSMITTAL 0 I.rV <br /> �1�/] <br /> ACCOUNT NO. DEPT, NO. REFERRAL �ILJI"�'J <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MITITLE LAST - AKA - FIRST MI TITLE <br /> GOLDEN GATE ORN IRON WORKS 1 1 . 11 111 11 111 ,11111 11111111 <br /> C/O NAME GUARANTOR SSN <br /> JESUS T VALENZUELA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2489 E MINER AVE STOCKTON CA 95205 209-941-4090 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-941-4090 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE CBM INT BM MONTHLY PAY AMT PYMAT,T TrphAnATF <br /> PR B <br /> 6139 HAZMAT 3/15/09 <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 DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $28.50 ` <br /> ,A <br /> State Surcharge Fee $24.00 <br /> Sm Hw Gen<5 Tons/yr $213.00 i <br /> Permit Fee Penalty $213.00 <br /> L` $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 /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2489 E MINER AVE STOCKTON CA 95205 <br /> spGu8& CO—OWNER <br /> AST FIRST MI TITLEJ SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2489 E MINER AVE STOCKTON I CA 5205 <br /> REPAREDBY ICHECKED BY DATE O Coy. M (3m) <br />