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:G # TO: OFFICE OF REVENUE AND RECOVERY <br /> Y ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ELKHORN COUNTRY CLUB <br /> C/O NAME GUARANTOR SSN <br /> NANCY CAPLIN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1050 ELKHORN DR STOCKTON CA 95209 209-477-8896 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4004 FT DONELSON DR STOCKTON CA 95219 209-951-9444 477 <br /> PYMT <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INTROEII MONTHLY PAY AMTnATP P <br /> 1371 HAZMAT I 1 11 11 11 1 1 1 1 1 1 1 1 1 1.4/1 <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 /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $315.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $311.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 360 042000.0 Electronic Surcharge Fee $25.00 380 1 11 042000.0 <br /> 380042000.0 380 042000.0 <br /> TOTAL $821.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ELKHORN COUNTRY CLUB 209-477-8896 X4118 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1050 ELKHORN DR STOCKTON CA 95209 <br /> CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ELKHORN COUNTRY CLUB 209-477-8896 X4118 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1050 ELKHORN D S O O CA 95209 <br /> REPARED BY CHECKED BY DATE ��� J� coL. 20 (ales) <br />