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CPG '# TO: OFFICE OF REVENUE AND RECOVERY <br /> �. ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NG. 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 /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I PY <br /> 12529 HAZMAT 3/20/11 <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 fHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $100.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $10.00 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380042000.0 <br /> TOTAL $159.00 <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 /> 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 /> SPOU&& CO-OWNER <br /> ST FIRST MI TITLEJ. SOC SEC NO, I DOB DR LIC NO AUTO LIC NO <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 T C S KTON I CA 1 95205 <br /> PREPARED BY I CHECKED B V 12ATE / /� coy 20 137 <br />