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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> RAMIREZ AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> ABEL RAMIREZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONENO. <br /> 2305 S AIRPORT WAY STOCKTON CA 95206 209-323-5117 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 6146 GREENFIELD LANE STOCKTON CA 95206 209-323-5117 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I PYM <br /> 14542 HAZMAT <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 /> 230 042000.0 2011 Hazmat Fee $100.00 380 042000.0 <br /> 230 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $100.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAMIREZ AUTO REPAIR 209-323-5117 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2305 S AIRPORT WAY STOCKTON CA 95206 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 1 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAMIREZ AUTO REPAIR 209-323-5117 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2305 S AIRPORT WAY STO ON CA 95206 <br /> 'REPAIRED BY CHECKED BY ATE �1/j j/ Coy. 20 (3M)) <br />