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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL . O (��'ULrJ)�V n <br /> ACCOUNT NO. DEPT. N REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> 77-71 ARTISTIC ORNAMENTAL IRON WORKS <br /> C/O NAME GUARANTOR SSN <br /> ALEX& ERNESTO GONZALEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2228 N WILSON WAY STOCKTON CA 95205 209-598-6673 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 1636 S AMERICAN ST STOCKTON CA 95206 209-465-7725 <br /> EI <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATE BM CBM IN MONTHLY PAY AMT PYMT P <br /> ROSIni,r nAT TERM 11T1 <br /> 2036 HAZMAT I 1 11 11 11 1 1 1 1 1 1 1 1 1 1.3/20/10 <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 HARGE DEPT.NO. DESCRIPTION AMOUNT <br /> Nn <br /> 230 026000.0 Sm Hw Gen<5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 lawk <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $788.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ARTISTIC ORNAMENTAL IRON WORKS 209-598-6673 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2228 N WILSON WAY STOCKTON CA 19520-5 <br /> SPOUSE- CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ARTISTIC ORNAMENTAL IRON WORKS 209-598-6673 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2228 N WILSON W Y T K CA 95205 <br /> PREPARED BY -- CHECKED BY ATE s— COL 20 (3ae) <br />