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CPG # TO: oICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL nATr Copy ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> WEST LANE RADIATOR <br /> C/O NAME GUARANTOR SSN <br /> FORTUNE&FORTUNE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3941 N WEST LN STOCKTON CA 95204 209-948-1638 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8312 BURGUNDY DR. STOCKTON CA 95210 209-948-1638 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATEI DATE TERM DATE <br /> BM CBMC INT MONTHLY PAY AMT <br /> 5601 HAZMAT I I 1 11 , 11 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> nnR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 6 Chems @ $15.00 Each $90.00 <br /> 10% Late Charge $33.00 <br /> State Service Fee $24.00 <br /> Sm Hw Gen <5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $813.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WEST LANE RADIATOR 209-948-1638 <br /> EMPLOYER STREET CITY ZIP ODE <br /> 3941 N WEST LN STOCKTON CA 95204 <br /> aPeUSE CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WEST LANE RADIATOR 209-948-1638 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3941 N WEST LN STOCKTON CA 95204 <br /> PREPARED I CHECKED BY � DATE / Coy. 20 (a8e <br /> IC7 �y off. <br />