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CPG # • TO: -- ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ,,,lf COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CAL TRANS (LINCOLN ST) <br /> C/O NAME GUARANTOR SSN <br /> STATE OF CALIFORN IA/DEPARTM ENT OF <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> CAL TRANS (LINCOLN ST) P.O. BOX 2048 STOCKTON CA 95201 209-948-3723 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1976 EAST CHARTER WAY STOCKTON CA 95205 209-948-7556(24 <br /> PYMT USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMTnaT PR B <br /> 5941 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 /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Surcharge Fee $24.00 19 <br /> TOTAL $321.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CAL TRANS (LINCOLN ST) 209-948-3723 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 312 S LINCOLN ST STOCKTON CA 95203 <br /> SPOUSE& 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 /> CAL TRANS (LINCOLN ST) 209-948-3723 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 312 S LINCOLN ST STOCKTON CA 9F03 <br /> PREPARED BY CHECKED BY I <br /> DATE , / 2 COL. 20(ase)) <br />