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CPG '# T0: OFFICE OF REVENUE AND RECOVERY COPY <br /> ACCOUNT TRANSMITTAL 0 <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> QUALITY CABINET SHOP <br /> C/O NAME GUARANTOR SSN <br /> QUALITY CABINET SHOP INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3256E TOMAHAWK DR STOCKTON CA 95205 209-948-0431 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3256 TOMAHAWK DR STOCKTON CA 95205 209-948-0431 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMC] CBMC INT MONTHLY PAY AMT I PYMT PROS <br /> 9458 HAZMAT 4/15/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> J <br /> STOP MED REC NO CHARGE <br /> DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NODESCRIPTION AMOUNT <br /> 042000.0 2011 Hazmat Fee $270.00 380 042000.0 <br /> 042000.0 Haz Mat Penalty Fee $27.00 380 042000.0042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $772.00 <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 /> QUALITY CABINET SHOP 209-948-0431 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3256 E TOMAHAWK DR STOCKTON CA 95205 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> QUALITY CABINET SHOP 209-948-0431 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3256 E TOMAHAW DR ST O TON CA 95205 <br /> PREPARED BY - _ CHECKED BY DATE 7�a O,1/ coy. zo (3/M) <br />