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CPG # TO: 'VICE OF REVENUE AND RECOVERY COPY <br /> a.e ACCOUNT TRANSMITTAL 1440ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ROOF RANGERS <br /> C/O NAME GUARANTOR SSN <br /> PATRICK W MAPLE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ROOF RANGERS P.O. BOX 5114 GALT CA 95632 209-745-5753 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PO BOX 5114 GALT CA 95632 209-745-5753 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBM INT MONTHLY PAY AMT <br /> PVIT PROB <br /> 13547 HAZMAT 3/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> .I I I I I 1 11 1 1 1 1 1 1 11 1 [ III JLII I III] , <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Kin230 026000.0 2009 Annual Fee $240.00 <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $28.50 <br /> State Surcharge Fee $24.00 <br /> TOTAL $337.50 <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 /> ROOF RANGERS 209-745-5753 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 129 HOOPER DR STOCKTON CA 95203 <br /> S-PAUSW!._ CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROOF RANGERS 209-745-5753 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 129 HOOPER DR STOCKTON CA 95203 <br /> REPARED BY ' CHECKED BY ATE 2�5 COL. 20 (3/80) <br /> r <br />