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CPG # T0: FFICE OF REVENUE AND RECOVERY • copy ACCOUNT TRANSMITTAL <br /> 5R(OSHAN <br /> . DEPT. NO. REFERRAL <br /> 026000.0 <br /> R - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> STATION LLC <br /> GUARANTOR SSN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> CALIFORNIA GAS STATION LLC 2420 W GRANT LINE RD TRACY CA 95376 408-239-9624 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TRACY CA 95376 209-832-8273 <br /> 1484 GABLE CT <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> PYMT PROB <br /> 12452 HAZMAT 4/15/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPTNODESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> . . <br /> 230 042000.0 2011 Hazrn Fee $100.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $10.00 380 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 $585.00 <br /> GUARANTOR <br /> DOBDR LIC IEEE LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CALIFORNIA GAS STATION LLC 408-239-9624 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1399E YOSEMITE AVE MANTECA CA 95336 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CALIFORNIA GAS STATION LLC 408-239-9624 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1399 E YOSEMITE AVE MANT CA CA1 95336 <br /> REPARED BY <br /> CHECKED BY DATE / ^� -/� COL. 2013/881 <br />