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CPG # TO: C 'ICE OF REVENUE AND RECOVERY CO p(\ <br /> ... ACCOUNT TRANSMITTAL yr O D V <br /> ACCOUNT NO. DEPT.NO. I DATE <br /> 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 NAW 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. I BILL SjAj CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> IF DAT M DATE <br /> 4853 HAZMAT 316104 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2004 Hmmp Annual Fee $240.00 <br /> 5 Chems @ $15.00 Each $75.00 <br /> 10% Late Charge $31.50 <br /> State Service Fee $24.00 <br /> TOTAL $370.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> D&V MACHINE SHOP&PUMP CO 209-948-0925 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1903 NAVY DR STOCKTON CA 95206 <br /> SPSr3SE 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 NAW DR STOCKTON CA 95206 <br /> PREPARED By <br /> / 1I CHECKED BY JDATE1COQ. 20 ivee <br />