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CPG # TO: 'wFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTALt0lpy <br /> 1,1 <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> LAKEWOOD AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> KEN PAIGE JR <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 103 E ELM ST LODI CA 95240 209-333-6300 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2828 CINNAMON TEAL CIR ELK GROVE CA 95757 209-481-3011 <br /> R <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PY B <br /> 7431 HAZMAT 3/15/09 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Kin <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $30.00 01 <br /> State Service Fee $24.00 <br /> Sm Hz Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> Addition Of 1 Chem $15.00 <br /> TOTAL $795.00 <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 /> LAKEWOOD AUTO REPAIR 209-333-6300 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 103 E ELM ST LODI CA 95240 <br /> SPASSE. 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 /> LAKEWOOD AUTO REPAIR 209-333-6300 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 103 E ELM ST LODI CA 1,95240 <br /> PREPARED BY CHECKED BY jDATE aJ coy 20 finee) <br />