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CPG # T0: .FICE OF REVENUE AND RECOVERY • COPY ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. I DATE REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CAR QUEST <br /> C/O NAME GUARANTOR SSN <br /> GOLDEN STATE SUPPLY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1645 E MINER AVE STOCKTON CA 95205 209-943-1000 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 34928 MC MURTREY WAY BAKERSFIELD CA 93305 209-943-1000 <br /> USER REFERENCE NO. I BILL STAI CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> DAT RM DATE <br /> 12410 HAZMAT 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> noR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE EP ;��,. -' DESCRIPTION'S AMOUNT <br /> No NO <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $25.50 <br /> State Service Fee $24.00 <br /> TOTAL $304.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CAR QUEST 209-943-1000 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1645 E MINER AVE STOCKTON CA 95205 <br /> 9F8S3H CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CAR QUEST 209-943.1000 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1645 E MINER AVE STOCKTON CA 95205 <br /> PREPARED BY CHECKED BY DATE coy. 20 ranee <br /> xn�Kr^ �� .� p <br />