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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> -_ ACCOUNT TRANSMITTAL � O py ACCOUNT NO. DEPT. N <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 7777 S BATES RD TRACY CA 209-346-4318 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 7777 BATES RD TRACY CA 209-836-1489 <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE BMI CBMI INT MONTHLY PAY AMT YMT PR <br /> 13574 HAZMAT 3/20/10 <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 $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <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 /> GILLS SMOG CHECK 209-346-4318 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 2171 E CHEROKEE RD STOCKTON CA 95205 <br /> SILOUSS CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB I DR LIC NO I AUTO LIC NO <br /> I 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 STOC ON CA 95205 <br /> PREPARED BY I CHECKED BY JDATE Z COL. 20 (3/BB) <br />