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CPG # TO: ICE OF REVENUE AND RECOVERY10 . <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT, NO. REFERRAL <br /> n AYC C (Dpy <br /> 11 1111o26aoo.o <br /> LAST - GUARANTOR - FIRST Ml TITLE LAST AKA FIRST MI TITLE <br /> JASON'S WHOLESALE (CLOSED) <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 /> 249-345-4371 <br /> USER REFERENCE NO. BILI TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT PYMT <br /> 13591 HAZMAT 7115109 <br /> CHARGES <br /> LAST - RECIPIENT FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <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 2007 - 2009 Annual <br /> Hmmp Fee $720.00 <br /> 3 Chems @ $15.00 <br /> Each Year $135.00 J ►_ <br /> 1 <br /> 10% Late Charge $85.50 I <br /> State Surcharge Fee $24.00 n / <br /> TOTAL $964.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST I ZIP CODE <br /> . i <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JASON'S WHOLESALE(CLOSED) 209-345-4371 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2444 STATION DR STE D STOCKTON CA 95215 <br /> S414AUSE_ CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NOAUTO LIC NO <br /> II I I I I I I t I 1 1". 1 1 1 1 1 t I El I I I I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JASON'S WHOLESALE (CLOSED) 249-345-4371 <br /> EMPLOYER STREET ( CITY ST ZIP CODE <br /> 2444 STATION DR STE D STOCKTON c / p CA 95215 <br /> PREPARED BY o, CHECKED BY ' DATE COL. 20 (3168) <br />