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TO: ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ACCOUNT NO. DEPT.NO. REFERRALDATE copy <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ESCALON,CITY OF PUBLIC WORKS <br /> 0/0 NAME GUARANTOR SSN <br /> CITY OF ESCALON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ESCALON,CITY OF PUBLIC WORKS(PRIMARY)P.O. BOX 248 ESCALON CA 95320 209-838-4139 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1854 MAIN STREET ESCALON CA 95320 209-838-4139 <br /> MoR <br /> USER REFERENCE NO. I BILLI STA CYCLEI STATUS DATEI BM CBMCJ INT I MONTHLY PAY AMT <br /> 6208 HAZMAT I I I I I I I I I I I I I I I I I I 1 113115108 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DO <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT,NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $30.00 - <br /> State Surcharge Fee $24.00 <br /> w- <br /> TOTAL $354.00 <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,CITY OF PUBLIC WORKS(PRIMARY) 209-838-4139 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2103 MAIN ST ESCALON CA 95320 <br /> 9E CO—OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SCALON,CITY OF PUBLIC WORKS(PRIMARY) 209-838.4139 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 2103 MAIN ST ESCALON CA 95320 <br /> REPARED BY CHECKED BY _ DATE l �� O q— COL. 20 ra�ea <br />