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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL copy <br /> ` 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 /> Tr <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CSMd INT MONTHLY PAY AMT MTrl <br /> PROS <br /> 5601 HAZMAT 1.3/20/1.0 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> non <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen<5tons/yr $213.00 <br /> 2010 Hazmat Fee $330.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 C <br /> Hazmat Penalty Fee $33.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $838.00 <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 ST ZIP CODE <br /> 3941 N WEST LN STOCKTON CA 95204 <br /> SPOU&& 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 CITYST ZIP CODE <br /> 3941 N WEST LN TOC 0 CA 95204 <br /> PREPARED B CHECKED BY DATE ���� COL 20 (3M) <br />