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CPG # TO: ICE OF REVENUE AND RECOVERY <br /> k ACCOUNT TRANSMITTAL C (0) FD—)yACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> AMERICAN CIVIL CONSTRUCTORS- <br /> C/O NAME ^T GUARANTOR SSN <br /> AMERICAN CIVIL CONSTRUCTORS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> AMERICAN CIVIL CONSTRUCTORS-WEST COAST 3701 MALLARD DR BENICIA CA 94510 707-333-2199 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3701 MALLARD DR BENICIA CA 94510 707-746-8028 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBMd INT MONTHLY PAY AMT <br /> 13579 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 13/15/09 <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 HARGE DEPT.NO. DESCRIPTION AMOUNT <br /> kin <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $25.50 <br /> State Surcharge Fee $24.00 <br /> TOTAL $304.50 <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 /> AMERICAN CIVIL CONSTRUCTORS-WEST COAST 707-333-2199 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1401 W WEBER AVE STOCKTON CA 95202 <br /> S?QU-&& CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AMERICAN CIVIL CONSTRUCTORS-WEST COAST 707-333-2199 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1401 W WEBER AVE STOCKTON CA 95202 <br /> REPARED BY CHECKED BY ATE c,� COL. n (3M) <br />