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CPv # TO: WICE OF REVENUE AND RECOVERY is <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> DATE <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CHEVRON#9-1452 <br /> C/O NAME GUARANTOR SSN <br /> CHEVRON PRODUCTS COMPANY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> CHEVRON#9-1452 P.O. BOX 6004 SAN RAMON CA 94583 925-842-9002 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 6004/ATTN: PERMIT DESK L2375-B1 SAN RAMON CA 94583-0904 925-842-9002 <br /> USER REFERENCE NO. BILL STA IF DAT TERM DATE <br /> CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> 4190 HAZMAT I I I I I I I I I I I I 1 11 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2008 Hmmp Annual Fee $70.00 Additional Ust $250.00 <br /> 5 Chems @ $15.00 Each $75.00 1 1 1 1 1 1 Ustacl I y& 1 Tank $550.00 <br /> 10% Late Charge $14.50 <br /> State Surcharge Fee $24.00 <br /> Sm Hw Gen <5tons/yr $213.00 <br /> Permit Fee Penalty $1013.00 <br /> Ust State Surcharge $45.00 <br /> TOTAL $2254.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CHEVRON#9-1452 925-842-9002 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 334 E MAIN ST RIPON CA 95366 <br /> 9meffM CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CHEVRON#9-1452 925-842-9002 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 334 E MAIN ST RIPON CA 95366 <br /> PREPARED BY L C CHECKED DATE�f ` �� COL. 20 (W8e <br />