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CPG # TO: ICE OF REVENUE AND RECOVERY COPY <br /> �.. ACCOUNT TRANSMITTAL �..( <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000-0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST . AKA - FIRST MI TITLE <br /> SPRAY-ON BEDLINERS OF STOCKTON <br /> C/O NAME GUARANTOR SSN <br /> MARY CLIFTON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> SPRAY-ON BEDLINERS OF STOCKTON 15687 S TALL TIMBER LN MOLALLA OR 97038-7406 209-401-0986 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1322 PONCE DE LEON AVE STOCKTON CA 95209 209-401-0986 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT <br /> PYMT PR <br /> 12081 HAZMAT 1.3/15/09 <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 /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Service Fee $24.00 <br /> TOTAL $321.00 <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 /> SPRAY-ON BEDLINERS OF STOCKTON 209-401-0986 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 720 E HAMMER LN E-9 STOCKTON CA 95210 <br /> SPOUS& CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SPRAY-ON BEDLINERS OF STOCKTON 209-401-0986 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 720 E HAMMER LN E-9 STOCKTON CA 1 95210 <br /> REPARED BY I CHECKED BY RATE [L �.0 D C� COL. n (3W) <br />