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CPG # TO: -"VICE OF REVENUE AND RECOVERY <br /> L, ACCOUNT TRANSMITTAL .,/ COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> R&B AUTO REPAIR 1 11 11 j 11 11 <br /> C/O NAME GUARANTOR SSN <br /> JERRY D ROARK <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> R&B AUTO REPAIR 1108 LAKEWOOD AVE MODESTO CA 95355 209-402-7810 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1108 LAKEWOOD AVE MODESTO CA 95355 209-402-7810 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBM INT MONTHLY PAY AMT <br /> 13685 HAZMAT 1.3/15/09 <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 /> CHkinARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 2008-2009 Late Charges $17.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $126.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME <br /> EMPLOYER PHONE NO <br /> R&B AUTO REPAIR 209-402-7810 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1211 S TURNPIKE RD STOCKTON CA 95206 <br /> S-PGUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> R&B AUTO REPAIR 209-402-7810 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1211 S TURNPIKE RD STOCKTON CA 9 O6 <br /> REPARED BY CHECKED BY - ATE y z.� COL. n/veal <br /> G _ <br />