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# 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 /> 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 TAT CYCLE STATUS DATE BMd CBM INT MONTHLY PAY AMTPYMT PROB <br /> 942 HAZMAT 4/15/11 <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 /> 230 042000.0 2011 Hazmat Fee $330.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $33.00 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <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 ZIP CODE <br /> 601 S WILSON WAY STOCKTON CA 95205 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ABC RADIATOR 209-463-7401 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 601 S WILSON WA STOCK, - ( CA 95205 <br /> REPARED BY L- / CHECKED BY JDATE f„�7- COL. 20 (3/68) <br />