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CPG # -- -- -- TO: _ 'FICE OF REVENUE AND RECOVERY ( tom/ <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> PY <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 720 E HAMMER LN STOCKTON CA 95210 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. I BILL STAI CYCLE STATUS DATE BMJ CBMC INT I MONTHLY PAY AMT <br /> QI IF DATE TERM DATE <br /> 12081 HAZMAT 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> Ong <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 1 026000.0 2008 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 /> 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 /> 9P68SR CO—OWNER <br /> LAST 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 /> PREPARED BYC/�, / ,, „ /9�� CHECKED BY ,� �Da ATE �/3. n� coy. zo �srea <br />