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CPG # TO: -7FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL �..! COPY ACCOUNT NO. DEPT. NO. REFER26000.0 RAL <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> LODI MOTORSPORTS (CLOSED) <br /> C/O NAME GUARANTOR SSN <br /> DAVE HARELL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> LODI MOTORSPORTS (CLOSED) 531 KANSAS AVE MODESTO CA 95351 (209)605-9779 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 409 COVENA AVE MODESTO CA 95354 (209)605-9779 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I PYMT R B <br /> nATF <br /> 13850 HAZMAT I 1 11 J I I I I I I I I I 1 1 1.3/20/1,1 <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 /> i <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEFT. �' DESCRI PI{IdiV AMOUNT <br /> mn 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 L 1 .\ <br /> I I 042000.0 Hazmat Penalty Fee $8.50 <br /> 380 042000.0 <br /> 380 042000.0 l' <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 /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI MOTORSPORTS (CLOSED) (209)605-9779 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 847 N CLUFF AVE#C LODI CA 95240 <br /> SPQWri& CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO I DOB DRLIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI MOTORSPORTS (CLOSED) (209)605-9779 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 847 N CLUFF AVE#C LODI CA 95240 <br /> REPARED BY i CHECKED BY JDATE ` Goy. 20 (3�ae) <br />