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CPG # �. TO: OFFICE OF REVENUE AND RECOVERY • COPY ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MANTECA EQUIPMENT RENTAL <br /> C/O NAME GUARANTOR SSN <br /> MANTECA EQUIP RENTAL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 616 S MAIN ST MANTECA CA 95337 209-239-3507 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 616 S. MAIN ST. MANTECA CA 95337 209-239-3507 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMI CBMI INT MONTHLY PAY AMT I PYMT PR B <br /> 968 HAZMAT 1. <br /> 3/20/10 <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 /> Kin <br /> 230 026000.0 Haz Mat 10% Late Charge $37.50 <br /> TOTAL $37.50 <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 /> MANTECA EQUIPMENT RENTAL 209-239-3507 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 616 S MAIN ST MANTECA CA 95337 <br /> SPOUSE- CO—OWNER <br /> I.AST FIRST MI TITLE SOC SEC NO I DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MANTECA EQUIPMENT RENTAL 209-239-3507 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 616 S MAIN ST MANTEC i _ CA 95337 <br /> REPARED BY 1 CHECKED BY ATE - O" /O coL. zo laieel <br /> / <br />