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CPG '# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL 0 �� <br /> ACCOUNT NO. DEPT. NO. REFERRnATC <br /> AL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ACTT 1 11 1 1111 111 111 1111 1111111111 <br /> C/O NAME GUARANTOR SSN <br /> ACTI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ACTI P.O. BOX 830 STOCKTON CA 95201 209-462-8241 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 18414 S. SANTA FE RANCHO -- CA 90221 310-763-1423 <br /> USER REFERENCE NO. BILL TAT ICYCLEISTATUS DATEI BM CBM INT MONTHLY PAY AMTFT, MT PROB <br /> 13311 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCENO/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 2010 Hazmat Fee $300.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 s$ <br /> Hazmat Penalty Fee $30.00 <br /> TOTAL $379.00 <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 /> ACTI 209-462-8241 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 935 E SCOTTS AVE STOCKTON CA 95205 <br /> SPOUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 1 I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ACTI 209-462-8241 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 935 E SCOTTS AVE STOCKTON CA 95205 <br /> PREPARED BY CHECKED BY DATE ,v//q //d COL 20 (3IBB) <br />