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1PG •7 TO: ceCE OF REVENUE AND RECOVERY <br /> TRANSMITTAL nM <br /> ACCOUNT NO. DEPT.NO. REFERRALFED)y <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> RAMIREZ AUTOMOTIVE (CLOSED) <br /> C/O NAME GUARANTOR SSN <br /> JUAN RAMIREZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 811 N SACRAMENTO ST LODI CA 95240 209-367-4332 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 315 S STOCKTON ST LODI CA 95240 209-367-4385 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BM CBMd INJ MONTHLY PAY AMT <br /> 6584 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REG NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> NA <br /> 230 042000.0 2012 Hazmat Fee $85.00 38q <br /> 30 1 014 90010 1 Hazmat Penalty Fee $8.50 p8q04 00 .0 <br /> 8q42900,0 Sm Hw Gen <5 Tons/yr $213.00 p8q <br /> p8q 0010 1 Permit Fee Penalty $213.00 8P44009.01 <br /> 80 1 014290010 State Surcharge Fee $24.00 8q 1 P43009.01 <br /> 80 1 014290010 Electronic Surcharge Fee $25.00 8q 11 043009.01 <br /> 80 1 002qOO.p P894 00 .0 <br /> TOTAL $568.50 <br /> PRIOR STREET CITY ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NOI <br /> RAMIREZ AUTOMOTIVE (CLOSED) 209-367-4332 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 811 N SACRAMENTO ST LODI CA 95240 <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 /> RAMIREZ AUTOMOTIVE (CLOSED) 209-367-4332 <br /> EMPLOYER STREET <br /> 811 N SACRAMENTO ST, L091 CA 95240 <br /> >/ , CHECKED BY JDATE ,I COL. 20 (3188) <br />