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CPG # TO: ICE OF REVENUE AND RECOVERY 0 py is ACCOUNT TRANSMITTAL <br /> ACCOUNT NO, DEPT. NO. <br /> REFERRAL • 0 <br /> 026000.0 <br /> MI TITLE <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST <br /> DERALD TORREY <br /> GUARANTOR SSN <br /> C/O NAME <br /> DERALD TORREY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> DERALD TORREY 135 PALM AVE RIPON CA 95366 <br /> 209-430-4077 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-430-4077 <br /> PYMT R B <br /> USER REFERENCE NO. BILL 3TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> 11/15/09 <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 /> CHARGEAMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> DEPT.NO. DESCRIPTION <br /> 230 026000.0 2008 - 2009 HmmP <br /> Annual Fee $480.00 <br /> 3 Chems @ $15.00 <br /> Each Year $90.00 <br /> 10% Late Charge $57.00 <br /> TOTAL $627.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO:E <br /> I 1 1 . , 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 <br /> CITY ST ZIP CODE <br /> CA 95205 <br /> 1020 E PARK ST STOCKTON <br /> SFAiIS 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 STOC ON <br /> CA 95205 <br /> REPARED B <br /> CHECKED BY,� — DATE / �,O coy. 2a (areal <br />