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^CPG # T0: ^FICE OF REVENUE AND RECOVERY • <br /> ACCOUNT TRANSMITTAL COPY ACCOUNT NO. DEPT. NO. REFERRAL <br /> TP <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CUSTOM METAL FINISHING <br /> C/O NAME GUARANTOR SSN <br /> NEIL DAVIS&TERRI TAYLOR <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1550 SHAW RD #CSTOCKTON CA 95215 209-505-0037 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4212 ELDENBERRY CT MODESTO CA 95356 209-918-0815 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYM P B <br /> 9554 HAZMAT 1.4/1 <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 042000.0 2011 Hazmat Fee $360.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $36.00 380 042000.0 <br /> 380 042000.0 Gen 5<25 Tons Permit $1672.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $1672.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 360 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $3789.00 <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 /> CUSTOM METAL FINISHING 209-505-0037 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1550 SHAW RD#C STOCKTON CA 95215 <br /> CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CUSTOM METAL FINISHING 209-505-0037 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1550 SHAW RD#C ST K O CA 95215 <br /> REPARED BY CHECKED BY DATE 'i� 7�� COL. 20 (IMA) <br />