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CPG"# T0: OFFICE OF REVENUE AND RECOVERY •j--- ACCOUNT TRANSMITTALcopy <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST MI TITLE <br /> STAPLES <br /> GUARANTOR SSN <br /> C/O NAME <br /> STAPLES <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-234-2195 EXT <br /> 4510 ALITALIA AVE #300STOCKTON CA 95206 ' <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> FRAMINGHAM MA 01702 508-253-5000 <br /> Soo STAPLES DR <br /> PYMT PROB <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMTDi <br /> 3/20/11 <br /> 9777 HAZMAT <br /> CHARGES <br /> LAST - RECIPIENT - FIRST <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPTNO. DESCRIPTION AMOUNT LARGE DEPT. NO. DESCRIPTION AMOUNT <br /> . <br /> 380 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $25.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL. $329.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO 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 /> CITY ST ZIP CODE <br /> EMPLOYER STREET <br /> CA 95206 <br /> 4510 ALITALIA AVE #300 STOCKTON <br /> Sggi3SE CO-OWNER <br /> AST <br /> FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> 209-234-2195 EXT <br /> STAPLES <br /> ECITY ST ZIP CODE <br /> EMPLOYER STREET <br /> 95206 <br /> 4510 ALITALIA AV 0 TO TON <br /> i� Cq <br /> 11 <br /> CHECKED BY DATE /` COL 20 131961 <br /> REPARED BY / <br />