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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> i ACCOUNT TRANSMITTAL <br /> 'COPY <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRA <br /> n ATP <br /> 026000.0 L <br /> LAST - GUARANTOR FIRST MI TITLE LAST AKA - FIRST M1 TITLE <br /> MOONLIGHT AUTO <br /> CIO NAME GUARANTOR SSN <br /> JOSE ROMERO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2560 S EL DORADO ST STOCKTON CA 95206 209-688-3247 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO.' <br /> STOCKTON CA 95206 209-547-8996 <br /> USER REFERENCE NO, BILLTAT CYCLE STATUS DATE SM CBM INT MONTHLY PAY AMT PYM PROS <br /> 13464 HAZMAT <br /> 3120114 <br /> CHARGES <br /> LAST - RECIPIENT FIRST. MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> DQ- <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPT. NO, DESCRIPTION' AMOUNT MARGE _ 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 />'I <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 /> MOONLIGHT AUTO 209-688-3247 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2560 S EL DORADO ST STOCKTON CA 95206 <br />� S�& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MOONLIGHT AUTO 209-688-3247 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2560 S EL DORADO ST 109 N CA 1 95206 <br /> REPARED BY CHECKED BY JDATE /a /0. COL 20(3188) <br /> i <br />