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CPG # T0: *ICE OF REVENUE AND RECOVERY • COPY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO, DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> COALCOMAN AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> JORGE DIAZ JR/RUBEN GARCIA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1042 S SINCLAIR AVE STOCKTON CA 95215 209-603-2161 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5262 E ARDELLE AVE. STOCKTON CA 95215 209-603-2161 <br /> USER REFERENCE NO. I BILL STA CYCLE STATUS DATEI BMd CBMC INT MONTHLY PAY AMT <br /> 13160 HAZMAT I I I I I I I I I I I I I 1 1 12/15/07 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2005-2007 Hmmp <br /> Annual Fee $210.00 <br /> 2 Chems @ $15.00 <br /> Each Year $90.00 <br /> 10% Late Charge $30.00 <br /> TOTAL $330.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> COALCOMAN AUTO REPAIR 209-603-2161 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1042S SINCLAIR AVE STOCKTON CA 95215 <br /> SP9SSE CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> COALCOMAN AUTO REPAIR 209-603-2161 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1042 S SINCLAIR AVE STOCKTON CA 95215 <br /> PREPARED BY, 1 CHECKED 5Y DATE I Coy. 20 r3res <br />