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CPG-# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL \�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 CBMd INT MONTHLY PAY AMT PYMT P111,p nAT TPPRA Dam <br /> 13547 HAZM AT 4/15/11 <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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Kin230 042000.0 2011 Hazmat Fee $285.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $28.50 380 042000.0 <br /> Ali- <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 3E0 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONENO <br /> ROOF RANGERS 209-745-5753 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 129 HOOPER DR STOCKTON CA 95203 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO, I DOB I DR LIC NO I AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROOF RANGERS 209-745-5753 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 129 HOOPER DR ST TO CA 95203 <br /> REPARED BY CHECKED BY / DATE // coy zo ((3 M) <br />