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CP # TO: ICE OF REVENUE AND RECOVERY <br /> ' ACCOUNT TRANSMITTAL Copy <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> D&V MACHINE SHOP&PUMP CO <br /> C/O NAME GUARANTOR SSN <br /> VAN LAWRENCE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 1903 NAVY DR STOCKTON CA 95206 209-948-0925 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 234 E ROBINHOOD DR STOCKTON CA 95219 209-948-0925 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BMd CBMC INT I MONTHLY PAY AMT <br /> 4853 HAZMAT 2/23/05 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <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 2005 Hmmp Annual Fee $240.00 <br /> 6 Chems C $15.00 Each $90.00 <br /> 10% Late Charge $33.00 <br /> State Service Fee $24.00 Vw <br /> TOTAL $387.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST I 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 /> SPeggfff CO-OWNER <br /> LAST 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 CITY ST ZIP CODE <br /> 1903 NAVY DR STOCKTON CA 95206 <br /> PREPARED BY CHECKED BYs <br /> DATE ;,1, 2y 0 COL. 20 fy� <br />