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CPG # _ T0: 'ICE OF REVENUE AND RECOVERY � �!✓ O <br /> ACCOUNT TRANSMITTAL ';/ ply <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> DATE <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> RAY FARMER ENTERPRISES <br /> C/O NAME GUARANTOR SSN <br /> RAY FARMER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> RAY FARMER ENTERPRISES 1117 LONE PALM AVE#B MODESTO CA 95351 209-579-2221 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3810 FOURTEEN MILE DR STOCKTON CA 95219-3809 209-952-3260 <br /> USER REFERENCE NO. I BILL STAA CYCLEI STATUS DATEI BMd CBMC INT I MONTHLY PAY AMTTERM DATE <br /> 7749 HAZMAT I I I I I I I I I I I I I I I I I I I2/23/05 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <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 026000.0 2005 Hmmp Annual Fee $70.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $8.50 <br /> State Service Fee $24.00 <br /> TOTAL $117.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAY FARMER ENTERPRISES 209-579-2221 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 61 ON HUNTER ST STOCKTON CA 95202-2022 <br /> SPeUSH CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAY FARMER ENTERPRISES 209-579-2221 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 610 N HUNTER ST STOCKTON CA 95202-2022 <br /> PREPARED BY,. I CHECKED B JDATE COL. 20 ryas <br />