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CPG :# T0: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL i <br /> copy <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> QATF <br /> 0420001 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> DAN'S AUTO REPAIR <br /> CIO NAME GUARANTOR SS <br /> N <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 /> USER REFERENCE NO. BILL STAI CYCLE STATUS DATEI BM CBMC INT MONTHLY PAY AMT ni]FnATF TF RM ATE <br /> 9131 HAZMAT 8115103 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> DOB <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 /> 380 0420001 2001-2003 Hmmp Annual <br /> Fee (3 Years Total) $210.00 <br /> 2 Chems @ $15.00 Each <br /> Per Year $90.00 <br /> 10% Late Charge $30.00 <br /> State Service Fee $17.50 <br /> TOTAL $347.50 <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 /> fR16kTOB CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB OR 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 /> // �. / / CHECKED BY DATE !�, Coy. 20 rias <br /> PREPARED SY <br />