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C,kG'# TO: O FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. N . REFERRAL <br /> 026000. <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 C 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. IBILL kTAT ICYCLE ISTATUS DATEI BMd CBMd INTI MONTHLY PAY AMTIr r)AT TFRKA DATI <br /> PR B <br /> 9458 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> Doe <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 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $270.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $27.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $772.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY STZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> QUALITY CABINET SHOP 209-948-0431 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 3256ETOMAHAWK DR STOCKTON CA 95205 <br /> SgBNSg 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 /> QUALITY CABINET SHOP 209-948-0431 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3256 E TOMAHAWKS <br /> PREPARED CK CA 95205 <br /> BY CHECKED BY DATE r'�Jp COL. 20 Gree) <br />