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CPG # TO: r-vICE REVENUE AND RECOVERY COPY <br /> ACCC OUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> KWIK STOP (CLOSED) 1 11 11 1 11 11 <br /> C/O NAME GUARANTOR SSN <br /> BALBIR CHADHA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 244W HARDING WAY STOCKTON CA 95204 209-948-8001 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-948-8001 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PY B <br /> 13395 HAZMAT 11/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICEDATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE mn DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2007 - 2008 Hmmp <br /> Annual Fee $140.00 <br /> 1 Chem @ $15.00 $30.00 <br /> 10% Late Charge $17.00 <br /> TOTAL $187.00 <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 /> KWIK STOP(CLOSED) 209-948-8001 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 244 W HARDING WAY STOCKTON Ci CA 95204 <br /> S?ABSCO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO I AUTO LIC NO <br /> EMPLOYER NAMEI I <br /> EMPLOYER PHONE NO <br /> KWIK STOP (CLOSED) 209-948-8001 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 244 W HARDING WAY T C T N CA 95204 <br /> REPARED 8 CHECKED BY p .sv- DATE / <br /> /b COL. 20 (398) <br />