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--- -------------------------- - ............... . .....-----. .... ... .. ------------------------------ <br /> CPG <br /> --- ------. -----CPG # TO: OCE OF REVENUE AND RECOVERY ❑ <br /> TRANSMITTAL C (D <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR -.FIRST MI TITLE LAST - AKA FIRST MI TITLE <br /> EASTSIDE AUTO REPAIR (CLOSED) <br /> CIO NAME GUARANTOR S5N <br /> EDMUNDO AYALA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4050 SECTION AVE STOCKTON CA 95215 209-462-1036 <br /> RESIDENCE STREET CITY ST ,ZIP CODE AREA PHONE NO. <br /> 1628 S ADELBERT AVE STOCKTON CA 95215 209-401-7080 <br /> USER REFERENCE NO. I BILL kTAT CYCLE STATUS DATE BMd CBMd INJ MONTHLY PAY AMT <br /> 10918 HAZMAT j 11 11 1 1 3115112 <br /> LAST - RECIPIENT - FIRST MI TITLE C[PIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO, DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $85.00 8q 1 P43009.01 <br /> 30 1 042 00 0 I Hazmat Penalty Fee $8.50 P89 1043009.01 <br /> 8 q42900ro Sm Hw Gen <5 Tons/yr $213.00 89 P43009-0 <br /> s a z o0 0 1 Permit Fee Penalty $213.00 p8q P43009.0, <br /> 800 2 00 0 State Surcharge Fee $24.00 8P44009,01 <br /> 80 I 0 2 Oa 0 11 Electronic Surcharge Fee $25.00 89 1 P43009.01 <br /> 80 11 002q00-p 11 p8q4 00 .D <br /> TOTAL $568.50 <br /> PRIOR STREET CITY sT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EASTSIDE AUTO REPAIR (CLOSED) 209-462-1036 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4050 SECTION AVE STOCKTON CA 95215 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I t I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EASTSIDE AUTO REPAIR(CLOSED) 209-462-1036 <br /> EMPLOYER STREET rITY 71P CODE <br /> 4050 SECTION AVE ST KT +�A95215 <br /> CHECKED BY DATE 1 001. 20 (3188) <br />