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CPG # _ TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL (DACCOUNT NO. DEPT. 0.0 REFERRAL \••�� V PY <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> POOL SUPPLIES & MORE it I <br /> C/O NAME GUARANTOR SSN <br /> AQUA POOL& SPA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> POOL SUPPLIES &MORE P.O. BOX 598 RIPON CA 95366-0598 209-652-1196 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 21238 S. MURPHY RD. RIPON CA 95366 209-249-6800 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMd INT MONTHLY PAY AMT I PY P . <br /> 13305 HAZMAT 1.3/20/1.1 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> mn <br /> 380 042000.0 2011 Hazmat Fee $285.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $28.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $362.50 <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 /> POOL SUPPLIES& MORE 209-652-1196 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2127 E MOFFAT BLVD MANTECA CA 95336 <br /> SPOU59 CO—OWNER <br /> ST FIRST MI TITI E SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> POOL SUPPLIES& MORE 209-652-1196 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2127 E MOFFAT BLVD NT A CA 95336 <br /> REPARED BY CHECKED BY L+ DATE ` b �f Cpl. pp (ygg) <br />