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----- ------ <br /> ------- ...... <br /> -------------------- <br /> CPG # TO: 0 E OF REVENUE AND RECOVERY <br /> zkrrnTTNrr, TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. COPY <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> TED'S WELDING&REPAIR <br /> C/O NAME GUARANTOR SSN I <br /> BILL(GEORGE) BRAUN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TED'S WELDING&REPAIR P.O. BOX 726 VICTOR CA 95253 209-368-9864 OR <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 611 VICTOR CA 95263 209-603-8979 <br /> USER REFERENCE NO. I BILL bTAT ICYCLE ISTATUS DATE I 13Md CBM d INMONTHLY PAY AMT I ni',PynMA'T VKU P <br /> ,P TPRA4 nAT <br /> 2876 HAZMAT 3/15/12 <br /> ENT <br /> LAST - RECIPIENT MCIPI <br /> FIRST MI TITLE Dog USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> START <br /> MED RE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> rj23 0 042000.0 2012 Hazmat Fee $285.00 8 1 P43009.01 1 <br /> ?301 1 0142q0010 I Hazmat Penalty Fee $28.50 8 1 1043009.01 1 <br /> p8q I 42 00 I Sm Hw Gen <5 Tons/yr $213.00 p8q 1 P43009.01 1 <br /> P84 1 0I42q0010 I Permit Fee Penalty $213.00 8 1 P43009.01 1 <br /> 801 1 042q0010 I State Surcharge Fee $24.00 p8q 1 P44009-01 1 <br /> ?801 1 002go0lo , Electronic Surcharge Fee $25.00 p8q 1 P43009.01 1 <br /> 801 11 002qOO.p I �Bq 1 P43009.01 I <br /> TOTAL $788.50 <br /> nr)R ng i ir Nn !��Q1 I AIUA—N!1!0 R. <br /> PRIOR STREET MTV IT ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TED'S WELDING&REPAIR 209-368-9864 OR 209 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 8932 E HWY 12 VICTOR CA 95253 <br /> AST FIRST MI TITLEJ SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TED'S WELDING & REPAIR 209-368-9864 OR 209 <br /> EMPLOYER STREET CITY sT 71P rnnF <br /> 8932 E HWY 12 VICTOR CA 95253 <br /> PREPARED I CHECKED 13Y IDATE COL. 20 (3188 <br />