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CPG' # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ACCOUNT NO. DEPT N REFERRALCOPY <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA FIRST MI TITLE <br /> PCI-PAINTING <br /> C/O NAME GUARANTOR SSN <br /> PCI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 SAN JUAN AVE STOCKTON CA 95203 209-460-0498 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 SAN JUAN AVE STOCKTON CA 95203 209-460-0498 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PR <br /> 13313 HAZMAT 3120110 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> Kin <br /> 230 026000.0 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 SAN JUAN AVE STOCKTON CA 95203 <br /> SPOUSFr CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 SAN JUAN AVE STO KT NCA 95203 <br /> PREPARED BY CHECKED aY DATEL��3 �f, COL. 20 (3133f <br />