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CPG"# TO: OFFICE OF REVENUE AND RECOVERY <br /> iAh ACCOUNT TRANSMITTAL � � rj--�1M <br /> ACCOUNT NO. DEPT. N REFERRAL 't�V J" lu( <br /> 026000.0 �! <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TRACY BP SERVICE CENTER <br /> C/O NAME GUARANTOR SSN <br /> KY TRAN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TRACY BP SERVICE CENTER 2375 N TRACY BLVD TRACY CA 95376 209-832-1650 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 2930 COMPTON PL TRACY CA 95377 209-832-1650 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMd INT MONTHLY PAY AMT P MT PR B <br /> 13300 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <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 Hazmat Penalty Fee $11.50 <br /> 2010 Hazmat Fee $115.00 Permit Fee Penalty $1138.00 <br /> Ust State Surcharge Fee $60.00 <br /> Additional Ust $375.00 <br /> Ust Facility& 1 Tank $550.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> TOTAL 4$2511.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TRACY BP SERVICE CENTER 209-832-1650 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2375 TRACY BLVD TRACY CA 95376 <br /> SFOUM CO—OWNER <br /> I.AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO I AUTO LIC NO <br /> I I i <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TRACY BP SERVICE CENTER 209-832-1650 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2375 TRACY BLVD TR Y, CA 95376 <br /> REPARED BY - CHECKED BY JDATE lb_ .7 f--'—i o COL. 20 (3188) <br />