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CPG # T0: �CE OF REVENUE 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 /> CASEY'S GIANT TIRE 111111111111 " 1 1111 111 <br /> C/O NAME GUARANTOR SSN <br /> CASEY PARSONS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> CASEY'S GIANT TIRE 1108 W TURNER RD LODI CA 95242-2353 209-339-4231 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1108 W.TURNER RD. LODI CA 95242 209-339-4231 <br /> USER REFERENCE NO. I BILL STA CYCLE STATUS DATE BMj CBMC INT I MONTHLY PAY AMT <br /> 12584 HAZMAT 12/15/07 <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 /> NO <br /> 230 026000.0 2002-2007 Hmmp <br /> AnnualFee $1440.00 <br /> 5 Chems @ $15.00 � I" <br /> Each Year $450.00 <br /> 10% Late Charge $189.00 tt ' <br /> v <br /> TOTAL 1$2079.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CASEY'S GIANT TIRE 209-339-4231 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1215 WATERLOO RD STOCKTON CA 95205 <br /> 6P6SSE CO-OWNER <br /> LAST FIRSTMI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CASEY'S GIANT TIRE 209-339-4231 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1215 WATERLOO RD STOCKTON CA 95205 <br /> PREPARED B C // TI CHECKED BY � ��� DATE I �, D� COLzo ryes <br />