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A <br /> CPG TO: ICE OF REVENUE AND RECOVERY <br /> f) • <br /> ACCOUNT TRANSMITTAL COPY ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MENDOZA'S AUTO BODY& PAINT <br /> C/O NAME GUARANTOR SSN <br /> JUAN MENDOZA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2538 N WEST LN #19-20STOCKTON CA 95205 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONENO. <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATEI BMI CBMd INTI MONTHLY PAY AMT I PYMT P <br /> 13884 HAZMAT 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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Nn <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 /> MENDOZA'S AUTO BODY& PAINT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2538 N WEST LN #19-20 STOCKTON CA 95205 <br /> SP49199 CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB I DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MENDOZA'S AUTO BODY& PAINT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2538 N WEST LN#19-20 STOC ON CA 95205 <br /> REPARED BY CHECKED BY &gkC,� DATE /� ,I coL 20 Israel <br />