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CPG # TO: "ICE OF REVENUE AND RECOVERY <br /> NW ACCOUNT TRANSMITTAL ..s � O (�1n/J <br /> ACCOUNT NO. DEPT. NO. REFERRAL \\U�/ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> EAGAL LAKES SPORT RESORTS <br /> C/O NAME GUARANTOR SSN <br /> JOHN EAGAL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> EAGAL LAKES SPORT RESORTS 9132 SANDRINGHAM CT STOCKTON CA 95209 209-481-1614 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 9132 SANDRINGHAM CT STOCKTON CA 95209 209-481-1614 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I T <br /> 12019 HAZMAT 1.7/1,5/0.9 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <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 026000.0 2009 Annual Hmmp Fee $70.00 <br /> 1 Chem C $15.00 $15.00 <br /> 10% Late Charge $8.50 <br /> State Surcharge 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 /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EAGAL LAKES SPORT RESORTS 209-481-1614 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 12 W LORENZEN RD TRACY CA 95304 <br /> SPOUfi& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EAGAL LAKES SPORT RESORTS 209-481-1614 <br /> EMPLOYER STREET CI Y ST ZIP CODE <br /> 12 W LORENZEN RD TRACY <br /> 'IiP4(, <br /> �� CA 95304 <br /> REPARED BY / CHE KED BY 4 DATE COL. 20 (3M) <br />