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CPG # TO: (`NICE OF REVENUE AND RECOVERY ACCOUNT TRANSMITTAL I.W <br /> REFERRAL COPY <br /> ACCOUNT NO. DEPT. NO. <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PALLET KING INC <br /> C/O NAME GUARANTOR SSN <br /> GEORGE MEDIEROS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PALLET KING INC P.O. BOX 31255 STOCKTON CA 95213 2095969166 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PO BOX 31255 STOCKTON CA 95213 2093375152 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I PY B <br /> 14050 HAZMAT 11/15/09 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> Kin <br /> 230 026000.0 2008 - 2009 Hmmp <br /> Annual Fee $140.00 <br /> 1 Chem @ $15.00 <br /> Each Year $30.00 <br /> 10% Late Charge $17.00 <br /> TOTAL $187.00 <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 /> PALLET KING INC 2095969166 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1881 E MARKET ST STOCKTON CA 95205 <br /> SPOUSE CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PALLET KING INC 2095969166 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1881 E MARKET ST STO TCA 95205 <br /> REPARED ByK ALE <br /> CHECKED BY -'- JDATE �7 p col. zo Iaiael <br />