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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> AM ACCOUNT TRANSMITTAL <br /> C (OPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA - FIRST MI TITLE <br /> R&S TRANSMISSION ti 111 [ 1 - 1 it 11 -1111711 <br /> CIO NAME GUARANTOR SSN <br /> MARIO & MARICELA REYNOSO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 24572 S MACARTHUR DR TRACY CA 95376 209-403-2093 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 6123 BREA AVE STOCKTON CA 95207 209-403-2093 <br /> USER REFERENCE NO. SILL TAT CYCLE ISTATUS DATE 13MJ CBMJ INT MONTHLY PAY AMT PYMT PROB <br /> 14299 HAZMAT 4/15111 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> ngla <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 2011 Hazmat Fee $85.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $8.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen<5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213-00 38D 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $568.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY 5T ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> R&S TRANSMISSION 209-403-2093 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 24572 S MACARTHUR DR TRACY CA 95376 <br /> CO—OWNER <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 /> R&S TRANSMISSION 209-403-2093 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 24572 S MACARTHUR DR TRA Y CA 95376 <br /> PREPARED BY 1 CHECKED BY JDAIE ? 71?�l coy 20 131ae1 <br />