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CPG # TO: FICE OF REVENUE AND RECOVERY <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 /> DERALDTORREY <br /> C/O NAME GUARANTOR SSN <br /> DERALDTORREY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> DERALD TORREY 135 PALM AVE RIPON CA 95366 209-430-4077 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209.430-4077 <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATEI BMI CBMC1 INT MONTHLY PAY AMT <br /> 3/20/11 <br /> 13573 HAZMAT <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTUSER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT, NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2011 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DERALD TORREY 209-430-4077 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 1020 W PARK ST STOCKTON CA 95205 <br /> SP9kJS� CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DERALD TORREY 209-430-4077 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1020 W PARK ST STOC O CA 95205 <br /> REPARED BY CHECKED B _ DATE v 8 coy. 20 is,ed <br />