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CPG '# TO: OFFICE OF REVENUE AND RECOVERY <br /> 026000.0 <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. REFERRAL [py <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GREEN HORIZON <br /> C/O NAME GUARANTOR SSN <br /> GREEN HORIZON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> GREEN HORIZON 540 FILLMORE ST SAN FRANCISCO CA 94117 209-466-8193 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 540 FILLMORE STREET SAN _ ,^^ CA 94117 415-255-0107 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBMI INT MONTHLY PAY AMT I"PYMT PROB <br /> 14177 HAZMAT 3/20/10 <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 /> wn <br /> 230 026000.0 2010 Hazmat Fee $270.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $27.00 <br /> TOTAL $346.00 <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 /> GREEN HORIZON 209-466-8193 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 611 GILMORE AVE STE B STOCKTON CA 95201 <br /> S-P0489 CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GREEN HORIZON 209-466-8193 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 611 GILMORE AVE STE B STOC TON CA 95201 <br /> PREPARED BY CHECKED BY IRATE l 0 1 COL. A) (3E8) <br />