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CPG #• TO: &ICE OF REVENUE AND RECOVERY • <br /> ACCOUNT TRANSMITTAL COPY <br /> • ACCOUNT NO, DEPT.NO. REFERRAL <br /> 026000.0 <br /> MI TITLE <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST <br /> SAN JOSE TALLOW <br /> C/O NAME GUARANTOR SSN <br /> MARK A ROSENZWEIG <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> SAN JOSE TALLOW 1350 REPORT AVE STOCKTON CA 95205 408-438-1401 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> SAN JOSE CA 95161 408-452-8777 <br /> P.O. BOX 610116 <br /> USER REFERENCE NO, BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> PYMT PROB <br /> 13734 HAZMAT 7/15/09 <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 Annual <br /> Hmmp Fee $480.00 <br /> 4 Chems @ $15.00 <br /> Each Year $120.00 <br /> 10% Late Charge $60.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $684.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZI�CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAN JOSE TALLOW 408-438-1401 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 1350 REPORT AVE STOCKTON CA 95205 <br /> SP9HS CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAN JOSE TALLOW 408-438-1401 <br /> EMPLOYER STREET ITY ST ZIP CODE <br /> 1350 REPORT AVE STOCKTON J� ? (< CA 95205 <br /> PREPAREDBY / CHECKE BY DATE coy. 20 Israel <br /> i <br />