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CPG # TO: FFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL Copy <br /> ACCOUNT NO. DEPT, NO. REFER <br /> 026000.0 RAL <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> HARPER BRUSH (CLOSED) <br /> C/O NAME GUARANTOR SSN <br /> MIKE MOTTET <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3632 PETERSEN RD STE 200STOCKTON CA 95215 209-948-9351 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3632 PETERSEN RD STE 200 STOCKTON CA 95215 209-948-9351 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT P M RKA n <br /> ATF <br /> 13238 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1.4/1,5/1.1 <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. DESCRI AMOUNT <br /> 11, <br /> 230 042000.0 2011 Hazmat Fee $285.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $28.50 380 042000.0Mika <br /> 380 042000.0 380 042000.0 <br /> 380 042000.0 360 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 1 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $362.50 <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 /> HARPER BRUSH (CLOSED) 209-948-9351 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3632 PETERSEN RD STE 200 STOCKTON CA 95215 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO I AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> HARPER BRUSH (CLOSED) 209-948-9351 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3632 PETERSEN S E20 TOCKTON CA 95215 <br /> REPARED BY CHECKED BY DATE a 7 �� coy. 20 caiael <br />