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# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL oppy <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ABC RADIATOR <br /> C/O NAME GUARANTOR SSN <br /> EDWARD FORTUNE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 601 S WILSON WAY STOCKTON CA 95205 209-463-7401 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-463-7401 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMCI INTIMONTHLY PAY AMT I P MT <br /> 942 HAZMAT 1. <br /> 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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> NIQ <br /> 230 026000.0 Sm Hw Gen<5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $330.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <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 /> ABC RADIATOR 209-463-7401 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 601 S WILSON WAY STOCKTON CA 95205 <br /> SPOUSE. 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 /> ABC RADIATOR 209-463-7401 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 601 S WILSON W Y ST CA 95205 <br /> REPARED BY CHECKED B DATE 6-)3�1b 1 COL. 20 )3/N) <br />