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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL . <br /> ACCOUNT NO. 0260000. REFERRAL <br /> C <br /> O �y026000.0 �l�rJJ <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TWO RIVERS R.V. PARK <br /> C/O NAME GUARANTOR SSN <br /> GEORGETURKMANY <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TWO RIVERS R.V. PARK P.O. BOX 1424 MANTECA CA 95336 209-914-6444 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONENO, <br /> 31021 TWO RIVERS RD. MANTECA CA 95337-9468 209-823-8434 <br /> USER REFERCLEENCE NO. BILL TAT CYSTATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PROB <br /> 12065 HAZMAT 3120110 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHNn ARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> TOTAL $329.50 <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 /> TWO RIVERS R.V. PARK 209-914-6444 <br /> EMPLOYER STREET CITY STf:Z:1P::C:q:0::D:E:::F31021 TWO RIVERS RD MANTECA CA337- 468 <br /> sgiw;S£- CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TWO RIVERS R.V. PARK 209-914-6444 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 31021 TWO RIVERS RD ANT A CA 95337-9468 <br /> REPARED BY CHECKED BY DATE !� ,2 3 1Q COL. 20 (3/88) <br />