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TO: OFFICE OF REVENUE & RECOVERY <br /> CPG: ACCOUNT TRANSMITTAL <br /> ACCOUNT NO DEPT NO REFERRAL DATE <br /> 0420000 <br /> LAST- -GUARANTOR- FIRST MI LAST AKA FIRST MI <br /> Jessup, John <br /> C/O Name SSN/FED# DR. LIC. NO. <br /> John Jessup Dream Rides <br /> MAILING STREET CITY ST ZIP AREA PHONE# <br /> 2383 N Wilson Way Stockton CA 95205 <br /> FACILITY ADDRESS CITY ST <br /> 1810 W Fremont St Stockton CA 95204 (209) 467-4669 <br /> USER REFERENCE NO <br /> Invoice #230830 <br /> COMMENTS: Q ,e <br /> SERVICE DATE: �) <br /> START: 1127112 STOP: 1/27/12 " -� <br /> CHARGE CHARGE <br /> No DEPT NO DESCRIPTION AMOUNT NO DEPT NO DESCRIPTION AMOUNT <br /> Inv #230837- <br /> 230 0420000 Hazmat Fee+1 yrs 170.00 <br /> Haz Mat Pen Fee 17.00 <br /> TOTAL 187.00 <br /> EMPLOYER NAME/SOURCE OF INCOME: EMPLOYER PRONE# <br /> EMPLOYER STREET CITY ISTI ZIP <br /> PREPARED BY: A IDATE: <br /> REVIEWED BY: DAT Z <br />