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CPG•#' TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL * copy c� Opy <br /> ACCOUNT NO. DEPT. NO. REFERRAL IU^J U <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JASON'S WHOLESALE <br /> C/O NAME GUARANTOR SSN <br /> JASON MATECKI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2444 STATION DR STE DSTOCKTON CA 95215 209-345-4371 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1369 SANTONA ST. MANTECA CA 95337 209-345-4371 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE "MCIN MONTHLY PAY AMT <br /> 14594 HAZMAT 3/15/1 1 . 2 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT,NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESC �. ; r LINT <br /> 230 042000.0 2012 Hazmat Fee $330.00 8q 1 043009.01 <br /> 30 1 014290010 1 Hazmat Penalty Fee $33.00 p8q1043009.01 <br /> p8q I 942900rO I State Surcharge Fee $24.00 38q4 00 .0 j <br /> p8q 1 0 290010 Electronic Surcharge $25.00 p8q %'.., <br /> 80 0 2 <br /> q0010 I p8q4 00 .0 <br /> 80 0 2 <br /> q0010 11 p8q <br /> 80 1 002qOO.p 11 p8q <br /> 1 11 <br /> TOTAL $412.00 <br /> GUARANTOR <br /> PRIOR STREET rnry ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JASON'S WHOLESALE 209-345-4371 <br /> EMPLOYER STREET CITYST ZIP CODE <br /> 2444 STATION DR STE D STOCKTON CA 95215 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JASON'S WHOLESALE 209-345-4371 <br /> EMPLOYER STREET CITY ST 71P C',QF)F <br /> 2444 STATION DR STE D STOC�KTON CA 95215 <br /> �RFPARFn Byi �.i .� CHECKED BY IDATE coy. zo laieel <br />