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CPG # TO: -ICE OF REVENUE AND RECOVERY Copy <br /> ACCOUNT TRANSMITTAL ACCOUNT NO. DEPT.NO. REFERRA <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> LODI PUBLIC WORKS <br /> C/O NAME GUARANTOR SSN <br /> CITY OF LODI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> LODI PUBLIC WORKS P.O. BOX 3006 LODI CA 95241-1910 209-333-6800 EXT <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 221 W PINE ST LODI CA 95241-1910 209-333-6706 <br /> USER REFERENCE NO. I BILL Sj�j CYCLEI STATUS DATE BM CBMCJ INT MONTHLY PAY AMT <br /> DUE DATE I TERM DATE <br /> 4384 HAZMAT j 2/23/05 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2005 Hmmp Annual Fee $70.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $10.00 <br /> State Service Fee $24.00 <br /> TOTAL $134.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI PUBLIC WORKS 209-333-6800 EXT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 210 W ELM ST LODI CA 95240 <br /> $PeUM CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI PUBLIC WORKS 209-333-6800 EXT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 210 W ELM ST LODI CA 95240 <br /> PREPARED BY I CHECKED BY DATE 27 c coL. 20 laree <br /> C 1 ,r <br />