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CPG'# TO: OFFICE OF REVENUE AND RECOVERY Q (0py <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ARMOR FIRE EXTINGUISHER CO <br /> C/O NAME GUARANTOR SSN <br /> ARMOR FIRE EXTINGUISHER CO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1321 W OAK ST STOCKTON CA 95203 209-547-1937 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-649-4430 <br /> SAME <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT P T R BTF <br /> 13915 HAZMAT 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 /> CHARGE DEPT. NO. DESCRIPTION AMOUNT F <br /> DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 VA <br /> Hazmat Penalty Fee $25.50 It <br /> TOTAL $329.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ARMOR FIRE EXTINGUISHER CO 209-547-1937 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1321 W OAK ST STOCKTON CA 95203 <br /> S-POW59 CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ARMOR FIRE EXTINGUISHER CO 209-547-1937 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1321 W OAK ST STOCKTON CA 95203 <br /> REPARED BY CHECKED BY ATE l�ja 3 r COL. 20 (3/88) <br />