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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL '+.,.. COPY <br /> ACCOUNT NO. DEPT. Na REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> FERMIN ALUSTIZA <br /> C/O NAME GUARANTOR SSN <br /> FERMIN ALUSTIZA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> FERMIN ALUSTIZA 8250 SEGARINI CT STOCKTON CA 95209 209-946-0450 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8250 SEGARINI CT STOCKTON CA 95209 209-472-9385 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PY PR <br /> 13611 HAZMAT 1.3/20/1.0 <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 2010 Hazmat Fee $270.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $27.00 <br /> TOTAL $346.00 <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 /> FERMIN ALUSTIZA 209-946-0450 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 820 CHANNEL ST STOCKTON CA 95202 <br /> SPQU4& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FERMIN ALUSTIZA 209-946-0450 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 820 CHANNELST STOCKTON CA 95202 <br /> PREPARED BY CHECKED BY JDATE COL. n (J <br />