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- CPG # TO: ^FFICE OF REVENUE AND RECOVERY Copy <br /> ACCOUNT TRANSMITTALACCOUNT NO. DEPT-NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GILLS SMOG CHECK <br /> C/O NAME GUARANTOR SSN <br /> BAGGA SINGH <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> GILLS SMOG CHECK 2171 E CHEROKEE RD STOCKTON CA 95205 209-346-4318 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONENO. <br /> 2171 E CHEROKEE RD STOCKTON CA 95205 209-946-9200 <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATE BMd CBMd INT MONTHLY PAY AMT <br /> 13574 HAZMAT 3/20/11 <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 /> 380 042000.0 2011 Hazmat Fee $85.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $8.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GILLS SMOG CHECK 209-346-4318 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2171 E CHEROKEE RD STOCKTON CA 95205 <br /> SPOUS& CO-OWNER <br /> I.AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GILLS SMOG CHECK 209-346-4318 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2171 E CHEROKEE RD STC? ON /7 1CA 95205 <br /> REPARED BY CHECKED BY DATE G coy. zo Isieel <br /> O <br />