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CPG' # T0: OFFICE OF REVENGE AND RECOVERY O �M <br /> ACCOUNT TRANSMITTAL \VU/ <br /> ACCOUNT NO. DEPT. NO. <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BETO AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> HERIBERTO C DIAZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 230 N PILGRIM ST STOCKTON CA 95205 209-430-3535 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-430-3535 <br /> USER REFERENCE NO. BILL TAT CYCLE STAT9DATEJBMC!1 [111NT1MONTHLY PAY AMT <br /> -04E4DAT-F— TERM DATE <br /> 14270 HAZMAT 3/15/12 <br /> uHKKQihs <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> ERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT, NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $85.00 8P43009.0 <br /> 30 042 00 0 Hazmat Penalty Fee $8.50 8 104300 .0 <br /> 8 42 00 0 I State Surcharge Fee $24.00 8q 043009.01 <br /> pq 000 1 ElectronicSurcharge $25.00 P89 P43002.0] <br /> a0 1 014290010 38q P43009.01 <br /> ao 1 014290010 8 43009.01 <br /> ao 1 0l42q00.paP43009.01 1 <br /> TOTAL $142.50 <br /> GUARANTI . . . ME I , i i I . . <br /> OR <br /> CITY �PCDEPRIOR STREET Z <br /> I <br /> EMPLOYER NAME EMPLOYER PHONENO <br /> BETO AUTO REPAIR 209-430-3535 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 230 N PILGRIM ST STOCKTON CA 95205 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BETO AUTO REPAIR 209-430-3535 <br /> EMPLOYER STREET <br /> 230 N PILGRIM ST STOCKTO CA 95205 <br /> PRIPPARED / ,.7 , <br /> COL zo (steel <br /> CHEC ED BY DATE . <br />