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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL C (D [py 026000.0 <br /> LAST GUARANTOR - FIRST MI TITLE LAST AKA - FIRST MI TITLE <br /> JK AUTOMOTIVE REPAIR <br /> C/O NAME GUARANTOR SSN <br /> DAVID GARZA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 710 E YOSEMITE AVE MANTECA CA 95336-5827 209-825-7340 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 710 E YOSEMITE MANTECA CA 95336 209-825-7340 <br /> USER REFERENCE NO. BILL 3TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PROS <br /> 9625 HAZMAT 3/20/10 <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 /> K1r) 410 <br /> 230 026000.0 Sm Hw Gen <5 Tons/yr $213.00 1 1 1 1 1 1 1 Follow Up For Non - <br /> 2010 Hazmat Fee $100.00 Compliance $57.50 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $10.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $642.50 <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 /> JK AUTOMOTIVE REPAIR 209-825-7340 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 710 E YOSEMITE AVE MANTECA CA 95336-5827 <br /> SPASSF- CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JK AUTOMOTIVE REPAIR 209-825-7340 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 710 E YOSEMITEdE=V A CA 95336-5827 <br /> REPARED BY CHECKED BY 7 JDATE COL. 20 (3/88) <br />