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CPG-# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL COPY I ' ll Ill . 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PACIFIC PULMONARY SERVICES 1 11 11 j 11 <br /> C/O NAME GUARANTOR SSN <br /> BRADEN PARTNERS, L.P. <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PACIFIC PULMONARY SERVICES 88 ROWLAND WAY NOVATO CA 94945 415-893-1518*239 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 88 ROWLAND WAY#300 NOVATO CA 94945 415-893-1518 <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATEI 13Md CBMd IN MONTHLY PAY AMT <br /> 10951 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE4-4 <br /> 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 /> 230 042000.0 2012 Hazmat Fee $255.00 8 1 P4009.O <br /> 30 1 014290010 1 Hazmat Penalty Fee $25.50 P8904 00 .o <br /> p8q I q429OOrO I State Surcharge Fee $24.00 p8q <br /> �8q 1 04290010 Electronic Surcharge Fee $25.00 p8q <br /> 1 1 <br /> ao I 02000 1 p8q400 .4 <br /> 1 11 <br /> ao 1 1 o 290010 s a 00 .o <br /> 1 11 <br /> 80 11 0 2(IOO.p I p8q4 00 .0 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> PRIOR STREET riTy T ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PACIFIC PULMONARY SERVICES 415-893-1518*239 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2666 N WEST LN#A STOCKTON CA 95205-2661 <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 /> PACIFIC PULMONARY SERVICES 415-893-1518*239 <br /> EMPLOYER STREET <br /> 2666 N WEST LN#A STOCKTO CA 95205-2661 <br /> CHECKED BY COL. 20 (3188) <br />