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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL �.d <br /> ACCOUNT NO. DEPT.NO. REFERRAL ICOPY <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SAFE DRAIN INC <br /> C/O NAME GUARANTOR SSN <br /> SAFE DRAIN INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> SAFE DRAIN INC P.O. BOX 612516 SAN JOSE CA 95161 408-738-6600 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PO BOX 723 OAKDALE CA 95361 408-738-6600 <br /> USER REFERENCE NO. IBILL kTAT ICYCLE STATUS DATEI BMd CBMd IN MONTHLY PAY AMT <br /> 13659 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> 4-4 <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT RCHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $255.00 4 00 .01 1 <br /> 30 042 000 Hazmat Penalty Fee $25.50 04 00 .08 42 000 State Surcharge Fee $24.00 4 00 .08 0 2 000 Electronic Surcharge $25.00 1 P43009.01 <br /> ?801 1 02000 111400 .0 <br /> 8 02000 I P8q400 .0 <br /> 80 1 0 2 00. 8q P43009.0, <br /> TOTAL $329.50 <br /> GUARANTOR <br /> PRIOR STREET CITY TZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAFE DRAIN INC 408-738-6600 <br /> EMPLOYERSTREET CITY ST I ZIPCODE <br /> 119 VAL DERVIN PKWY#1 STOCKTON CA 1 95206 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAFE DRAIN INC 408-738-6600 <br /> EMPLOYER STREET CITY <br /> 119 VAL DERVIN PKWY ST, ON CA 1 95206 <br /> �RFPAgrn ByD B COL 20 (3188) <br />