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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL REFERRAO ACCOUNT NO. DEPT. NO. L [py <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MASTER AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> CESAR DAVILA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> MASTER AUTO REPAIR 1803 SHADY FOREST WAY STOCKTON CA 95205-2588 209-464-1935 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3630 GAMBEL OAK LANE STOCKTON CA 95205 209-464-1935 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I TP <br /> P PR B <br /> 13367 HAZMAT 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 AMOUNTCHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Nn <br /> 230 026000.0 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $115.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $11.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $601.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIPCODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MASTER AUTO REPAIR 209-464-1935 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3091 N WILSON WAY STOCKTON CA 95205 <br /> SF6HS9 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 /> MASTER AUTO REPAIR 209-464-1935 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3091 N WILSON WAY ST K CA 95205 <br /> REPARED BY CHECKED BY DATE -a --�Q COL. 20 (31W) <br />