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CPG # TO: ""FICE OF REVENUE AND RECOVERY COPY <br /> ACCOUNT TRANSMITTAL <br /> DATE <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> C DEJONG TRUCKING INC <br /> C/O NAME GUARANTOR SSN <br /> DEJONG TRUCKING <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> C DEJONG TRUCKING INC P.O.BOX 126 RIPON CA 95366 209-599-4187 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 126 RIPON CA 95366 209-599-4187 <br /> USER REFERENCE NO. I BILLI STAI CYCLE1 STATUS DATEI BMI CBMCJ INT MONTHLY PAY AMT up DATE I TERM CATE <br /> 3174 HAZMAT 3/21/04 <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 /> NONO <br /> 230 026000.0 2004 Hmmp 10% <br /> Late Charge $30.00 <br /> Permit Fee Penalty $200.00 <br /> TOTAL 1 $230.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> C DEJONG TRUCKING INC 209-599-4187 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 24975 S AUSTIN RD RIPON CA 95366 <br /> 9i&ebfG;} CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> C DEJONG TRUCKING INC 209-599-4187 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 24975S AUSTIN RD RIPON Cq 95366 <br /> PREPARED BY E ,.K o.. CHECKED BY a L,i .L��ATE /7 A, COL 20 ryes <br />