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-CPG 31= . TO: rJr-YICE OF REVENUE AND RECOVERY - <br /> ACCOUNT TRANSMITTALCOFT <br /> %LAWRENCE <br /> DEPT. NO. REFERRAL ,!026000.0 <br /> - FIRST MI TITLE LAST - AKA - FIRST <br /> RAI TITLE <br /> & PUMP CO <br /> GUARANTOR SSN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1903 NAVY DR STOCKTON CA 95206 <br /> 209-948-0925 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 234 E ROBINHOOD DR STOCKTON CA 95219 209- 092 <br /> 5 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT P M B <br /> 483 HAZMAT 3/20/1 <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 /> CHKin ARGE DEPT. NO. DESCRIPTION AMOUNT HARGE D O. SCRIPTION AMOUNT <br /> 230 026000.0 2011 Hazmat Fee $300.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 P <br /> Hazmat Penalty Fee $30.00 <br /> } <br /> TOTAL $379.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D&V MACHINE SHOP& PUMP CO 209-948-0925 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1903 NAVY DR STOCKTON €- CA 95206 <br /> SPARSCO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D&V MACHINE SHOP& PUMP CO 209-948-0925 <br /> EMPLOYER STREET I CITY ST ZIP CODE <br /> 1903 NAVY DR STOCKTD CA 95206 <br /> PREPARED BY I CHECKED BYATE 7 // coy. 10 (area) <br />