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CPG # TO: --FICE OF REVENUE AND RECOVERY <br /> �.. ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CRYSTAL VALLEY CELLARS LLC <br /> C/O NAME GUARANTOR SSN <br /> COSENTINO SIGNATURE ENT <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> CRYSTAL VALLEY CELLARS LLC P.O. BOX 1827 WOODBRIDGE CA 95258-1827 707-944-1220 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 7415 HWY 29 YOUNTVILLE CA 94599 707-944-1220 <br /> USER REFERENCE NO. IBILL bTAT ICYCLE ISTATUS DATE1 BMd CBMd INT MONTHLY PAY AMT <br /> 'YM <br /> I III E 01 <br /> 12301 HAZMAT 11 1 1 j I I I I I I 1,3tl5/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE-. DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEkin DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $30.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $354.00 <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 /> CRYSTAL VALLEY CELLARS LLC 707-944-1220 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 16750E HWY 88 LOCKEFORD CA 95237 <br /> SPOUS& CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CRYSTAL VALLEY CELLARS LLC 707-944-1220 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 16750 E HWY 88 LOCKEFORD CA P237, <br /> PREPARED BY CHECKED BY I ATE ` ,� �j GOL p 13WI <br />