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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> O ��ACACCOUNT TRANSMITTAL <br /> C <br /> COUNT NO. DEPT. N� REFERRAL � <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ULLOA'S TOW& AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> ULLOA'S TOW&AUTO REPAIR <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 S WILSON WAY STE CSTOCKTON CA 95205 209-943-0588 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-943-0588 <br /> PYMT ' I USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMTIP nAT Rhh n <br /> ATr <br /> 12529 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> Dam <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 2010 Hazmat Fee $100.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $10.00 mvk <br /> TOTAL $159.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITYST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ULLOA'S TOW&AUTO REPAIR 209-943-0588 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 S WILSON WAY STE C STOCKTON CA 95205 <br /> S?9HS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO, I DOB I DR LIC NO I AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ULLOA'S TOW&AUTO REPAIR 209-943-0588 <br /> EMPLOYER STREET CITYST ZIP CODE <br /> 620 S WILSON WAY STE C STO KTON CA 95205 <br /> PREPARED BY CHECKED BY ATE 41/x3 0 1 COL. ZO (388) <br />