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CP('"# T0: OFFICE OF REVENUE AND RECOVERY 0 [py <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST MI TITLE <br /> DERALD TORREY <br /> GUARANTOR SSN <br /> C/O NAME <br /> DERALD TORREY <br /> ET CITY ST ZIP CODE AREA PHONE NO <br /> MAILING STRE . <br /> 209-430-4077 <br /> DERALD TORREY 135 PALM AVE RIPON CA 95366 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-430-4077 <br /> USER REFERENCE NO, BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> PYMT PR B <br /> 3/20/10 <br /> 13573 HAZMAT <br /> CHARGES <br /> LAST - RECIPIENT - FIRST <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPT. NO. AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> DESCRIPTION <br /> 230 026000.0 2010 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 /> CITY ST ZIP CODE <br /> PRIOR STREET <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DERALD TORREY 209-430-4077 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> CA 95205 <br /> 1020 E PARK ST STOCKTON <br /> SPA8S1'r CO—OWNER <br /> AST <br /> 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 E PARK ST S OC ON CA 95205 <br /> REPAIRED BY <br /> CHECKED BY DATE l�� �O COL 20 (3IBB) <br />