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CPG # TO: --FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL COPY 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 ZIPCODE 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 TATICYCLEISTATUSDATEIBMTCBmd INT MONTHLY PAY AMTPR B <br /> 13611 HAZMAT 3/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> mn <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $321.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FERMIN ALUSTIZA 209-946-0450 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 820 CHANNEL ST STOCKTON CA 95202 <br /> SPAUSS- CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <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 1 95202 <br /> PREPARED BY I CHECKED BY DATE COL. 20 (3M) <br /> C <br />