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CPG^ $ TO: OFFICE OF REVENUE AND RECOVERY [py <br /> ACCOUNT TRANSMITTAL Qc 0 <br /> ACCOUNT NO. DEPO.T.N <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> STAPLES <br /> C/O NAME GUARANTOR SSN <br /> STAPLES <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4510 ALITALIA AVE #300STOCKTON CA 95206 209-234-2195 EXT <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 500 STAPLES DR FRAMINGHAM MA 01702 508-253-5000 <br /> PROB <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 9777 HAZMAT 3/15/12 <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 2012 Hazmat Fee $300.00 08 4 00 .0 <br /> 30 01429000 Hazmat Penalty Fee $34.50 8 04 00 .0 <br /> 8 42 00 0 State Surcharge Fee $24.00 p8q <br /> �8q I 0 2 90010 1 Electronic Surcharge Fee $25.00 p8q <br /> so 0 2 00 0 I p8q4 00 .0 <br /> 80 014220010 8 4 009.0 <br /> 80 11 0 2 00-P 11 I218q <br /> TOTAL $383.50 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> STAPLES 209-234-2195 EXT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4510 ALITALIA AVE#300 STOCKTON CA 95206 <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LICNO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> STAPLES 209-234-2195 EXT <br /> EMPLOYER STREET <br /> 4510 ALITALIA AVE#300 STP TON CA 95206 <br /> ECKED BY DATE COL 20 (meal <br />