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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> AN ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL " Copy <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> RALPH'S STATUARY <br /> C/O NAME GUARANTOR SSN <br /> RALPH P LOMELI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> RALPH'S STATUARY 3741 TINA PL STOCKTON CA 95215-1109 209-464-0745 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3604 MUNFORD AVE STOCKTON CA 95215 209-464-0745 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PROS <br /> 10054 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 /> CHARGEMn I DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> TOTAL $329.50 <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 /> RALPH'S STATUARY 209-464-0745 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3602 E MUNFORD AVE STOCKTON CA 95215 <br /> SP9U" CO-OWNER <br /> AST FIRST MI TITLESOC SEC NO. I DOB DR LIC NO I AUTO LIC NO <br /> I 1 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RALPH'S STATUARY 209-464-0745 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3602 E MUNFORD AVE ST N CA 95215 <br /> PREPARED BY CKT CHECKED BY DATE 3 l,D COL. 20 (3M) <br />