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CPG # T0: OFF IOF REVENGE AND RECOVERY COPY <br /> ..ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CLARKLIFT TEAM POWER <br /> C/O NAME GUARANTOR SSN <br /> JOE HENSLER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1268 VANDERBILT CIR #1MANTECA CA 95337 209-239-1350 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8111 FRUITRIDGE RD SACRAMENTO CA 95826 916-381-4000 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT]MONTHLY PAY AMT PYM P B <br /> 9163 HAZMAT 7/15/08 <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 /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Addition Of 1 Chemical $15.00 <br /> 10% Late Charge $1.50 <br /> TOTAL $16.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LICNO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CLARKLIFT TEAM POWER 209-239-1350 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1268 VANDERBILT CIR#1 MANTECA CA 95337 <br /> SPOUSE CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CLARKLIFT TEAM POWER 209-239-1350 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1268 VANDERBILT CIR#1 MANTECA CA 95337 <br /> REPARED BY CHECKE1jV DATE COL. zo (5199) <br /> �1e� //�i%/J'& AAL <br /> t.t7 <br />