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^PG # TO: O]�.. CE OF REVENUE AND RECOVERY 1 <br /> TRANSMITTAL COPY ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GUARANTEE REPAIR SERVICE <br /> C/O NAME GUARANTOR SSN <br /> BONNIE BERNEISER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO <br /> GUARANTEE REPAIR SERVICE P.O. BOX 246 VICTOR CA 95253-0246 209-339-1100 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO <br /> 12611 E PELTIER RD ACAMPO CA 95220 209-369-8373 <br /> USER REFERENCE NO. BILL hTAT CYCLE I STATUS DATE BM CBMd INd MONTHLY PAY AMT <br /> 4649 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1, 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> STAR STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $300.00 p8q <br /> 1 1 <br /> 30 042 90010 Hazmat Penalty Fee $30.00 p8q04 00 .0 <br /> 8q42900,0 Sm Hw Gen <5 Tons/yr $213.00 P84 <br /> 1 1 <br /> �Bq 1 014290010 Permit Fee Penalty $213.00 P894 009.01 <br /> 80 11 0I42q0010 I State Surcharge Fee $24.001 '4,00',0 <br /> 80 11 0142900,0 Electronic Surcharge Fee $25.00P89 11 P43009.01 <br /> 80 11 0200.p 1 �89 11 P43009.01 <br /> TOTAL $805.00 <br /> DR I IC NO QXARANMOR <br /> PRIOR STREET rITY qT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> GUARANTEE REPAIR SERVICE 209-339-1100 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 101 COMMERCE ST LODI CA 95240-0845 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GUARANTEE REPAIR SERVICE 209-339-1100 <br /> EMPLOYER STREET CITY ST 71P <br /> 101 COMMERCE LO CA 95240-0845 <br /> CHECKED BY JDATE COL. 20(X8e) <br />