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CPG;# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL REFERR "COPY <br /> r' ACCOUNT NO. DEPT. NO. <br /> 026000.0 'ATrAL <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ALONSO'S AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> HUMBERTO ALONSO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1021E PARK ST STOCKTON CA 95202 209-941-9026 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-941-9026 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> PYMT PROS <br /> 14265 HAZMAT 3/20/10 <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 & 2010 Hazmat Fee $200.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $20.00 <br /> TOTAL $269.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> EEMPLOYER <br /> EK= <br /> DE <br /> I <br /> EPAIR ODE <br /> 1021 E PARK ST STOCKTON <br /> SP9IiSE CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LICNO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ALONSO'S AUTO REPAIR 209-941-9026 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1021E PARK ST STOCKTON CA 95202 <br /> REPARED BY CHECKED BY DATE 311 Coy. 20 (cree) <br />