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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> T^ ACCOUNT TRANSMITTAL <br /> ...rc <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> COPY <br /> 026000.0 <br /> LAST GUARANTOR FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> JEFF ROGERS TRUCKING <br /> C/O NAME GUARANTOR SSN <br /> EARL JEFFREY ROGERS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> JEFF ROGERS TRUCKING P.O. BOX 30698 STOCKTON CA 95215 209-944-9414 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3973 SUNNY ROAD STOCKTON CA 95215 209-944-9414 <br /> USER REFERENCE NO. BILL bTATICYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT PYMT B <br /> 14124 HAZMAT <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 CHARGEtin DEPT. NO. IPTlON AMOUNT <br /> 230 026000.0 2005 - 2009 <br /> 10% Late Charge $63.75 1 <br /> f <br /> L <br /> i <br /> k.TOTAL $63.75 <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 /> JEFF ROGERS TRUCKING 209-944-9414 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3526 MUNFORD AVE STOCKTON CA 95215 <br /> SPOUSE- CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JEFF ROGERS TRUCKING 209-944-9414 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3526 MUNFORD AVE STOCKTO CA P5215 <br /> PREPARED BY CHECKED BY DATE 7 `d COL. zo (MS) <br />