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CPO,# TO: OFFICE OF REVENUE AND RECOVERY III U <br /> I � ACCOUNT TRANSMITTAL REFERRAL <br /> I I <br /> 1C <br /> ACCOUNT NO. DEPT. U. I <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST MI TITLE <br /> POLYBAU PRIMA PRODUCTS <br /> GUARANTOR SSN <br /> C/O NAME <br /> PRIMA PRODUCTS, INC. DBA POLYBAU I I I CITY ST ZIP CODE AREA PHONE NO. <br /> MAILING STREET (209)830-5170 <br /> 1851 PARADISE RD ATRACY CA 95304 <br /> CITY ST ZIP CODE AREA PHONE NO. <br /> RESIDENCE STREET CA 95304 (209) 830-5170 <br /> TRACY <br /> 1851 E. PARADISE RD. PYMT PROS <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> 3/20/10 <br /> 12158 HAZMAT <br /> CHARGES <br /> - <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> LAST - RECIPIENT FIRST <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION <br /> AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> D08 DR LICNO HJAUTO LIC NO <br /> CITY ST ZIP CODE <br /> PRIOR STREET <br /> EMPLOYER PHONE NO <br /> EMPLOYER NAME (209)830-5170 <br /> POLYBAU PRIMA PRODUCTS CITY ST ZIP CODE <br /> EMPLOYER STREET CA 95304 <br /> 1851 PARADISE RDA TRACY <br /> CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. <br /> DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER PHONE NO <br /> EMPLOYER NAME (209) 830-5170 <br /> POLYBAU PRIMA PRODUCTS CITY ST ZIP CODE <br /> EMPLOYER STREET CA 95304 <br /> 1851 PARADISE RD A TR CY DATE 7 �' /�'d COL. 20(3W) <br /> REPARED BY <br /> CHECKED BY <br />