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CPG # TO: ^VFICE OF REVENUE AND RECOVERY <br /> _ ACCOUNT TRANSMITTAL \-c0 <br /> LJ <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ESCALON AUTO&TRUCK REPAIR <br /> C/O NAME GUARANTOR SSN <br /> JOE KOWALSKI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ESCALON AUTO&TRUCK REPAIR 1623 3RD ST ESCALON CA 95320 209-838-8215 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1623 3RD STREET ESCALON CA 95320 209-838-8215 <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I PYMT P <br /> ROB <br /> 12227 HAZMAT 3/15/09 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> wn <br /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $13.00 <br /> State Surcharge Fee $24.00 <br /> Sm Hw Gen <5tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $593.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ESCALON AUTO&TRUCK REPAIR 209-838-8215 <br /> EMPLOYER STREET CITY STZIP ODE <br /> 1925 JACKSON AVE ESCALON CA 95320 <br /> SPOUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ESCALON AUTO&TRUCK REPAIR 209-838-8215 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1925 JACKSON AVE ESCALON CA 95320 <br /> REPARED BY CHECKED BY DATE -/Ib COL. M(area) <br />