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CPC-' # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL TIMI( <br /> Fl <br /> ACCOUNT NO. DEPT.NO. REFERRAL -1 0 U <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 ICYCLE ISTATUS DATE BMd CBMd INd MONTHLY PAY AMT <br /> 13547 HAZMAT 1. 3/15/12 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> pip ldn <br /> 230 042000.0 2012 Hazmat Fee $285.00 p8q4 00 .0 <br /> 30 1 014290010 1 Hazmat Penalty Fee $28.50 p8q04 0P.0, <br /> 8 42 00 0 I State Surcharge Fee $24.00 p8q 1 P43009.01 <br /> 8 0I42q0010 Electronic Surcharge Fee $25.00 p8q <br /> 1 1 <br /> 80 11 0 2 00 0 8 4 00 .01 11 <br /> 8011 0 2 00 0 p8q P43009.01 <br /> 60 11 002q00.P I p8q400 .0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR I Ir.NO Al <br /> PRIOR STREET rfTY T 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 1 95203 <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROOF RANGERS 209-745-5753 <br /> EMPLOYER STREET CITY RT 71Prnnr <br /> 129 HOOPER DR 11 STOCK ON CA 95203 <br /> CHECKED BY IDATE COL. 20 (area) <br />