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CPG # TO: i�ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 1 ATE <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> HENKELS AND MCCOY <br /> C/O NAME GUARANTOR SSN <br /> C.T.TITUS&L.M. ETAL <br /> MAILING STREET CITY ST ZIPCODE AREA PHONE NO. <br /> 17751 S IDEAL PKWY MANTECA CA 95336 209-823-0454 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 21881 PHOENIX LAKE RD SONORA CA 95370 209-931-5325 <br /> ppoir— <br /> USER REFERENCE NO. I BILL SjAj CYCLE STATUS DATE BMd CBMC INT I MONTHLY PAY AMT 11 I'Iyl',TI TERM DATE <br /> 9900 HAZMAT I I I I I I I I I I I I 1 3/15/07 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO, DESCRIPTION AMOUNT <br /> NO <br /> 230 026000.0 2007 Hmmp Annual Fee $70.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $10.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $134.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CrTY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> HENKELS AND MCCOY 209-823-0454 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 17751 S IDEAL PKWY MANTECA CA 95336 <br /> SPEIUM CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> HENKELS AND MCCOY 209-823-0454 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 17751 S IDEAL PKWY MANTE CA 95336 <br /> PREPARED B CHECKED BY <P <br /> DATE/ / O COL. 20 �aree <br /> 7 <br />