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CPG # TO: CE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL �y <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MUFFLER MAN (LODI) <br /> C/O NAME GUARANTOR SSN <br /> JIM LOOCK/LOOCK LIVING TRUST <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 827 N SACRAMENTO ST LODI CA 95240-1252 209 333 2556 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 423 1/2 POPLAR ST LODI CA 95240 209-333-2556 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> PYMT PROB <br /> 7626 HAZMAT 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> k <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $25.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> DOB I DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MUFFLER MAN (LODI) 209 333 2556 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 827 N SACRAMENTO ST LODI CA 95240-1252 <br /> SFL 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 /> MUFFLER MAN (LODI) 209 333 2556 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 827 N SACRAMENTO ST LODI CA 95240-1252 <br /> REPARED BY CHECKED IS JDATE b , coL. zo Israel <br />