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CPG # - 'T0: ICE OF REVENUE AND RECOVERY . ply ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> QUINTERO'S Q-LUBE&TUNE <br /> CIO NAME GUARANTOR SSN <br /> OMAR JASON QUINTERO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2521 N WEST LN STOCKTON CA 95205 209-948-1452 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2135 PISA CRL STOCKTON CA 95206 209-948-1452 <br /> USER REFERENCE NO. 61LL STAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> "YM' PROB <br /> 12048 HAZMAT 917104 <br /> CHARGES <br /> LAST RECIPIENT - FIRST Mi TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> DOR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE1 DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NO <br /> 230 026000.0 2004 Hmmp Annual Fee $70.00 <br /> 1 Chem @ $15.00 $15.00 r <br /> 10% Late Charge $8.50 <br /> ..5 <br /> State Service Fee $24.00 <br /> Stormwater Inspection $50.00 <br /> Lj <br /> TOTAL $167.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> QUINTERO'S Q-LUBE&TUNE 209-948-1452 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2521 N WEST LN STOCKTON CA 95205 <br /> SpEydsB CO—OWNER <br /> LAST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> QUINTERO'S Q-LUBE&TUNE 209-948-1452 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2521 N WEST LN STOCKTON f <br /> CA 95205 <br /> PREPARED BY; / CHECKED BY DATE �0y ,F cam 20 lyse <br />