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CPG # TO: 0 CE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • OPY ACCOUNT NO. DEPT.NO. REFERRAL C�026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> EXEL(IMPERIAL) <br /> C/O NAME GUARANTOR SSN <br /> EXEL INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> EXEL(IMPERIAL) 3735 IMPERIAL WAY STOCKTON CA 95215 209-942-0102 EXT <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 570 POLARIS PARKWAY WESTERVILLE OH 43082 614-865-8500 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMI IN MONTHLY PAY AMT <br /> 12035 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 /> 230 042000.0 2012 Hazmat Fee $345.00 p8q 1 P43009.01 <br /> 30 0142900 o Hazmat Penalty Fee $34.50 paq104300P.0 <br /> p8q I q429OOrO I State Surcharge Fee $24.00 p8q 1 P43009.01 <br /> �8q I o z 00 0 I Electronic Surcharge Fee $25.00 P89 <br /> 80 I o z o0 0 I Cal Arp State Surcharge $270.00 P89 li 4 300P.0 <br /> 80 1 04290010 aP43009.01 <br /> 80 1 0 2qOO.p I p8q <br /> TOTAL $698.50 <br /> GUARANTOR <br /> PRIOR STREE riTy qT ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EXEL(IMPERIAL) 209-942-0102 EXT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3735 IMPERIAL WAY STOCKTON CA 95215 <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 /> EXEL(IMPERIAL) 209-942-0102 EXT <br /> EMPLOYER STREET <br /> 3735 IMPERIAL WAY S11 C N CA 95215 <br /> i CHECKED BY IDATE COL. 20 (3188) <br />