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CPG` # TO: OFFICE REVENUE AND RECOVERY - O py ACCC OUNT TRANSMITTALCODEPACCOUNT NO. T. NO. REFERRAL MATC <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> WESTERN ORGANICS <br /> C/O NAME GUARANTOR SSN <br /> WESTERN ORGANICS H 11 <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> WESTERN ORGANICS 420 E SOUTHERN AVE TEMPE AZ 95282 917-922-2899 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 420 E. SOUTHERN AVE. TEMPE AZ 85282 800-352-3245 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INd MONTHLY PAY AMT <br /> 13606 HAZMAT 1,3/15/12 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $345.00 p8q <br /> 1 1 <br /> 30 1 114290110 1 Hazmat Penalty Fee $34.50 P84104300P.0 <br /> p8q I q42900fO I State Surcharge Fee $24.00 p8q <br /> 1 1 <br /> p8q 1 014290010 Electronic Surcharge Fee $25.00 p8q <br /> 1 1 <br /> 80 0 2 0010 1 p8q4 00 .0 <br /> 80 0 2 00 0 I �8q 1, P43009.0, <br /> 80 1 0 2qOO.p pq P43002.0, <br /> TOTAL $428.50 <br /> GUARANTOR <br /> PRIOR STREET ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WESTERN ORGANICS 917-922-2899 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4343 MCKINLEY AVE FRENCH CAMP CA 95231 <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 1 I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WESTERN ORGANICS 917-922-2899 <br /> EMPLOYERSTREET CITY qT 71P r.OnF <br /> 4343 MCKINLEYAVE F ENC, CAMP CA 95231 <br /> CHECKED D COL 20 <br />