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CPG.'# TO: OFFICE OF REVENUE AND RECOVERY - <br /> ACCOUNT TRANSMITTAL COPY <br /> +• REFERRAL ACCOUNT NO. DEPT. NON► <br /> 026000.0 <br /> ITLE <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIHST MI T <br /> PRODUCTION CAR CARE PROD(1015) <br /> C/O NAME GUARANTOR SSN <br /> LEWYN BOILER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PRODUCTION CAR CARE PROD(1015) 1000 E CHANNEL ST STOCKTON CA 95205 209-483-2454 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1000 E. CHANNEL ST. STOCKTON CA 95205 209-943-73371 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMTTFL <br /> V PR <br /> 1313 HAZMAT <br /> 3/20/11 <br /> CHARGES <br /> 1111 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Kin <br /> 380 1 042000.0 2011 Hazmat Fee $690.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $69.00 <br /> 380 042000.0 - <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $808.00 <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 /> PRODUCTION CAR CARE PROD (1015) 209-483-2454 <br /> EMPLOYER STREET I CITY ST ZIP CODE <br /> 1015 E CHANNEL ST STOCKTON CA 95205 <br /> SPBU& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME I EMPLOYER PHONE NO <br /> PRODUCTION CAR CARE PROD (1015) 209-483-2454 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1015 E CHANNEL ST STC N CA 95205 <br /> 'REPAIRED BY CHECKED B 1-,i JDATE /6,^f r I COL. zo J1,R) <br />