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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL C <br /> 0py <br /> ACCOUNT NO. DEPT. NO. REFERRAL <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. BILL kTAT CYCLE STATUS DATE BM CBMI INT MONTHLY PAY AMT PYMT <br /> 13659 HAZMAT 3/20/10 <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 /> 230 026000.0 2010 Hazmat Fee $270.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 gala. am <br /> Hazmat Penalty Fee $27.00 low <br /> TOTAL $346.00 <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 ZIP CODE <br /> 119 VAL DERVIN PKWY#1 STOCKTON CA 95206 <br /> SPOUS& CO-OWNER <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 ST ZIP CODE <br /> 119 VAL DERVIN PKWY#1 STIOCKTON CA 95206 <br /> PREPARED BY I CHECKED BY JDATE y1a9J/D I COL. M (3rea) <br />