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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ^hfJ <br /> ACCOUNT NO. DEPT. NO. REFERRAL nAll /l/`vJJ,/„`(J{(•�J/ \j{-'�/ <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 ZIPCODE AREA PHONENO, <br /> 8312 BURGUNDY DR. STOCKTON CA 95210 209-948-1638 <br /> USER REFERENCE NO. BILLTAT CYCLE STATUS DATE BMI CBM INT MONTHLY PAY AMT I PY PROB <br /> 5601 HAZMAT 1.4/1 <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 Nn DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. N R �� AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $330.00 380 042000. w kw wp - <br /> 230 042000.0 Hazmat Penalty Fee $33.00 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> Sao 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 3a0 Oat I ' Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL 4$838.00L <br /> GUARANTOR <br /> DOB OR 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 ST I ZIP CODE <br /> 3941 N WEST LN STOCKTON CA 1 95204 <br /> CO—OWNER <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 /> WEST LANE RADIATOR 209.948-1638 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3941 N WEST LN STOCKY, Cq 95204 <br /> REPARED BY CHECKED BY DATE 7;2 <br /> Q^// COL. 20 laiael <br />