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CPG'# TO- OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> -AST GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> ROCKITE CO <br /> CIO NAME GUARANTOR SSN <br /> NEIL DAVIS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1550 SHAW RD #DSTOCKTON CA 95215 209-918-0815 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4212 ELDENBERRY CT MODESTO CA. 95356 209-918-0815 <br /> USER REFERENCE NO. BILL 3TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT PYMT PR B <br /> 13907 HAZMAT 3120111 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> QQw <br /> SERVICE DATE- DATE OF <br /> START STOP MED REC NO CHANGE <br /> CHARGE DEPT NO DESCRIPTION AMOUNT CHARGE DEPT. NO DESCRIPTION AMOUNT <br /> Kin <br /> 380 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <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 DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY St ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROCKITE CO 209-918-0815 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1550 SHAW RD#D STOCKTON CA 95215 <br /> SPOUS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I l i <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROCKITE CO 209-918-0815 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1550 SHAW RD#D S OCKTOVAI C CA 95215 <br /> PREPARED BYCHECKED BY DATE // _ COL 20 (3188) <br />