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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> IS ACCOUNT TRANSMITTAL * COPY O ��V <br /> n <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> A-1 TRANSMISSIONS <br /> C/O NAME GUARANTOR SSN <br /> ERIC GOODMAN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3132N WILSON WAY STOCKTON CA 95205 209-477-1492 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4576 WINDING RIVER CIR. STOCKTON CA 95207 209-477-1492 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMTIII I PR B <br /> 10631 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 AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen<5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $100.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $10.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $585.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A-1 TRANSMISSIONS 209-477-1492 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3132 N WILSON WAY STOCKTON CA 95205 <br /> SPOU,8g CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 1 I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A-1 TRANSMISSIONS 209-477-1492 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3132 N WILSON WAY STS CA 1 95205 <br /> REPARED BY CHECKED BY"t JDATE J COL. 20 I3M <br />