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ti <br /> PG # TO: r'^-FICE OF REVENUE AND "RECOVERY <br /> ACCOUNT .TRANSMITTAL D <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRAL <br /> o2s000.o _ <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA FIRST MI TITLE <br /> UNITED GAS <br /> GUARANTOR SSN <br /> CIO NAME <br /> TIRATH GILL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 440 W CHARTER WAY STOCKTON CA 95206 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 95377 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> P MT PR B <br /> 9814 HAZMAT 3115109 <br /> CHARGES <br /> LAST RECIPIENT FIRST <br /> 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 2009 Hmmp Annual Fee $240.00 <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $28.50 <br /> rWState Service Fee $24.00 <br /> Sm Hw Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $763.50 <br /> GUARANTOR <br /> DOB DR LEC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> f <br /> i EMPLOYER NAME EMPLOYER_PHONE NO <br /> UNITED GAS <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 440 W CHARTER WAY STOCKTON CA 95206 <br /> S1PQU4& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I EMPLOYER NAME EMPLOYER PHONE NO <br /> UNITED GAS <br /> j EMPLOYER STREET CITY ST ZIP CODE ' <br /> i 440 W CHARTER WAY STOCKTON CA 95206 <br /> PREPARED BY CHECKED BY DATE b COL. 20(3188) <br /> 1 <br />