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CPG # TO: FFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • COPYnAT <br /> ACCOUNT NO. DEPT. NO. 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 /> FRAMINGHAM MA 01702 508-253-5000 <br /> 500 STAPLES DR <br /> PYMT PROS <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> 9777 HAZMAT 11/15/11 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 Addition Ot 3 Chems $45.00 380 042000.0 <br /> 230 042000.0 Hazmat Penalty Fee $4.50 380 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 042000.0 380 040 <br /> 2 00.0 <br /> TOTAL $49.50 <br /> GUARANTOR <br /> DOB DR LIC NOAUTO LIC NO <br /> CITY ST ZIP CODE <br /> PRIOR STREET <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> 209-234-2195 EXT <br /> STAPLES - <br /> EMPLOYER STREET <br /> CITY ST ZIP CODE <br /> 4510 ALITALIA AVE#300 STOCKTON CA 95206 <br /> CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> 209-234-2195 EXT <br /> STAPLES - <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4510 ALITALIA AV #3 0 TOCK N CA 95206 <br /> REPARED BY , CHECKED BY IUAIE Coy. 20 (3W) <br />