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CPG # TO: FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTALclpy <br /> ACCOUNT NO. DEPT,NO. REFERRAL 1J <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA - FIRST MI TITLE <br /> JASON'S WHOLESALE <br /> CIO NAME GUARANTOR SSN <br /> JASON MATECKI <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 2540 STATION DR DSTOCKTON CA 95215 2093454371 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2540 STATION DR. SUITE C&D STOCKTON CA 95215 2093454371 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMC INT MONTHLY PAY AMT PYMT PROB <br /> 14198 HAZMAT 1 1 1.3/20/1.1 <br /> CHARGES <br /> LAST - RECIPIENT FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT NO. DESCRIPTION AMOUNT <br /> NQ <br /> 380 042000.0 2011 Hazmat Fee $315.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $31.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $395.50 <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 /> JASON'S WHOLESALE 2093454371 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2540 STATION DR D STOCKTON CA 95215 <br /> SPOUSZ- CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ,JASON'S WHOLESALE 2093454371 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2540 STATION DR D STOCK,TCA 95215 <br /> REPARED BY - CHECKED B DATE / �' r/ Cot. 20 (sisa) <br />