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CPG' # ' T0: &ICE OF REVENUE AND RECOVERY • <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT,NO. REFERRAL <br /> DATE <br /> 026000.0 <br /> LAST - GUARANTOR FIRST Ml TITLE LAST - AKA - FIRST MI TITLE <br /> DAN'S AUTO REPAIR 11 11 1 111 ll �jj- 1 II <br /> .CIO NAME GUARANTOR SSN <br /> DAN HOUSTON <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1533 S STOCKTON ST LODI CA 95240 209-334-2969 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> .209-334-2969 <br /> PROS <br /> USER REFERENCE NO. BILL STAA CYCLE STATUS DATE BMq CBMC INT I MONTHLY PAY AMT <br /> UE DATE-j-TEsmp <br /> 9131 HAZMAT 3115106 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF ^ D <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2006 Hmmp Annual Fee $70.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $10.00 " <br /> State Surcharge Fee $24.00 <br /> TOTAL $134.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DAN'S AUTO REPAIR 209-334-2969 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1533 S STOCKTON ST LODI CA 95240 <br /> flE4N:FSB CO—OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> HOUSTON PAULA <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DAN'S AUTO REPAIR 209-334-2969 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1533 S STOCKTON ST LODI CA 95240 <br /> PREPARED B I CHECKED BY RE5- �� <br /> COL. 20 c�ee <br />