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CPG # T0: OFFICE OF REVENGE AND RECOVERY <br /> ACCOUNT TRANSMITTAL 0 PIDACCOUNT NO. DEPT. NO. REFERRAL U <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE ;LAST - AKA - FIRST MI TITLE <br /> OGC/O NAME GUARANTOR S <br /> MARIA SERRATO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3227 E MAIN ST ASTOCKTON CA 95205 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> Yn <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 13061 HAZMAT <br /> 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DAT DATE OF <br /> RT STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NR Wi <br /> 230 042000.0 2012 Hazmat Fee $85.00 p8q <br /> 30 1 014290010 Hazmat Penalty Fee $8.50 P894 00 .0 <br /> p8q I q429OOrO I State Surcharge Fee $24.00 p8q <br /> p8q <br /> 1 014290010 Electronic Surcharge $25.00 8 <br /> 6 2 00,0 p8q4 00 .0 <br /> 8 020008 400 .0 <br /> 80 0 2 00. 8P43009.01 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PAYLESS SMOG <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 3227 E MAIN ST A STOCKTON CA 1 95205 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PAYLESS SMOG <br /> EMPLOYER STREET <br /> 3227E MAIN ST A STOCKTO/ CA 95205 <br /> PRFPARFng CHECKED BY IDATE COL 20 (3M) <br />