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CPG"# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ` <br /> ACCOUNT NO. DEPT.7. REFERRAL-1 19C <br /> D <br /> 026000.0 <br /> 1 1 1 1 1 1 1 --" I a 1 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA FIRST MI TITLE <br /> WATERLOO LIQUOR &GAS MART <br /> C/O NAME GUARANTOR SSN <br /> PHALWINDER SINGH /LOVEJEST KAUR I <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5611 E WATERLOO RD STOCKTON CA 95205 209-473-4270 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3039 PETIT LANE STOCKTON CA 95212 209-931-2942 <br /> USER REFERENCE NO. BILL 3TAT CYCLE STATUS DATE BM CBM INTI MONTHLY PAY AMT P M PR06 <br /> 10996HAZMAT 3/20110 <br /> . [ I I I I <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> pow <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen<5tons/yr $213.00 Hazmat Penalty Fee $30.00 <br /> 2010 Hazmat Fee $300.00 Permit Fee Penalty $1013.00 <br /> Ust State Surcharge Fee $45.00 <br /> Additional Ust $250.00 <br /> Ust Facility& 1 Tank $550.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> TOTAL $2450.00 <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 /> WATERLOO LIQUOR &GAS MART 209-473-4270 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 5611 E WATERLOO RD STOCKTON CA 95205 <br /> SP9UM CO—OWNER <br /> ST FIRST MITITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WATERLOO LIQUOR &GAS MART 209-473-4270 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 5611 E WATERLO RDSC, GA 95205 <br /> PREPARED BY CHECKED BY DATE Z}.-/ COL 20 (3188) <br />