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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL "we026000.0 <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 it <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 ZIPCODE AREA PHONE NO. <br /> PO BOX 723 OAKDALE CA 95361 408-738-6600 <br /> PR <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMC INT MONTHLY PAY AMT I m <br /> PYMT <br /> 13659 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1.3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $25.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $329.50 <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 /> SAFE DRAIN INC 408-738-6600 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 119 VAL DERVIN PKWY#1 STOCKTON CA 95206 <br /> S-PGU" 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 /> SAFE DRAIN INC 408-738-6600 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 119 VAL DERVIN K Y 1 S CKTON CA 1 95206 <br /> COL zo (VAR)REPARED BY CHECKED BY <br />