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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ..r Copy <br /> ACCOUNT NO. DEPT. NO, REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> FERGUSON WATERWORKS <br /> C/O NAME GUARANTOR SSN <br /> FERGUSON ENT <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1102S AURORA ST STOCKTON CA 95206 209-933-0529 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 12500 JEFFERSON AVE NEWPORT VA 23602 757-874-7795 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMCj INT MONTHLY PAY AMT I nt PYMT PROB <br /> 14090 HAZMAT3/20/11 <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 026000.0 2011 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <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 /> FERGUSON WATERWORKS 209-933-0529 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1102S AURORA ST STOCKTON CA 95206 <br /> SPOUSE- CO-OWNER <br /> I.AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FERGUSON WATERWORKS 209-933-0529 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1102 S AURORA ST O T, CA 95206 <br /> REPARED BV CHECKED BY DATE 5—��7/�/ COL. 20 (area) <br />