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'G # TO: 0CE OF REVENUE AND RECOVERY <br /> T <br /> ACCOUNT TRANSMITTAL . 0 1 1 <br /> O DM( <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 9/10/02 ���/// UUU U <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> LODI AIRPORT <br /> C/O NAME GUARANTOR SSN <br /> ROBERT KUPKA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> LODI AIRPORT P.O. BOX 10 ACAMPO CA 95220 209-369-9126 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-369-9126 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BM CBMC INT I MONTHLY PAY AMT DI JF DATE TERM DATE <br /> 9457 HAZMAT I I I I I I I I I I I I 1 6/17/02 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> nng <br /> SERVICE DATE.- DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2002 Hmmp Annual Fee $240.00 Business Owner: <br /> 1 Chem @ $15.00 Each $15.00 Robert Kupka <br /> 24 WA-F 4AR4 674 A- <br /> 10% Late Charge $25.50 <br /> Previously Referred: <br /> gal <br /> TOTAL $280.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI AIRPORT 209-369-9126 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 23987 N HWY 99 ACAMPO CA 95220 <br /> 813@HSE CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LODI AIRPORT 209-369-9126 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 23987 N HWY 99 ACAMPO CA 95220 <br /> PREPARED IjY.r�, ' „ CHECK IP JDATE 9/10/02 <br />