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CPG # TO. vICE OF REVENUE AND <br /> RECOVERY <br /> ACCOUNT TRANSMITTAL .� OP�/] <br /> ACCOUNT NO. DEPT. NO. REFERRAL V <br /> � C <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JOHN MANSU&SON (CLOSED) <br /> C/O NAME GUARANTOR SSN <br /> JOHN MANSU <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> JOHN MANSU&SON (CLOSED)21750 KENNIFICK RD ACAMPO CA 95220 209-810-2171 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 21750 KENNIFICK RD _ ACAMPO CA 95220 209-810-2171 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I PYMT PR B ATr <br /> 13771 HAZMAT 1.7/1 <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 /> Nn <br /> 230 026000.0 2008 & 2009 Annual <br /> Hmmp Fee $480.00 <br /> 1 Chem @ $15.00 L—RAP Ail <br /> Each Year $30.00 AVA <br /> 10% Late Charge $51.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $585.00 <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 /> JOHN MANSU &SON (CLOSED) 209-810-2171 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1026 BLACK DIAMOND WAY LODI CA 95240 <br /> SPAU9& CO–OWNER <br /> ST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JOHN MANSU &SON (CLOSED) 209-810-2171 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1026 BLACK DIAMOND WAY LODI 22' p CA 95240 <br /> REPARED BY I CHECKED BY JDATE cOL. 20 (3M) <br />