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CP`� TO: ICE OF REVENUE AND RECOVERY C <br /> ACCOUNT TRANSMITTAL 0 '1 �)Y ACCOUNT NO. DEPT.NO. REFERRAL 'U^J <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST MI TITLE <br /> CALIFORNIA DEPT FISH&GAME <br /> C/O NAME GUARANTOR SSN <br /> CALIFORNIA DEPT OF FISH&GAME <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4001 N WILSON WAY STOCKTON CA 95205-2486 209-948-3702 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1416 NINTH ST SACRAMENTO CA 95814 916-653-7667 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BMC CBMC INT MONTHLY PAY AMT <br /> 6387 HAZMAT 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> J:: <br /> QR <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 2008 Hmmp Annual Fee $240.00 <br /> i <br /> 3 Chems @ $15.00 Each $45.00 j <br /> 10% Late Charge $28.50 <br /> State Surcharge Fee $24.00 <br /> Sm Hw Gen <5tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> Calarp State Surcharge $270.00 J <br /> TOTAL 1$1033.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CALIFORNIA DEPT FISH&GAME 209-948-3702 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4001 N WILSON WAY STOCKTON CA 95205-2486 <br /> 9peH9E CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CALIFORNIA DEPT FISH&GAME 209-948-3702 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4001 N WILSON WAY STOCKTON CA 95205-2486 <br /> PREPARED BY _ I CHECKED BY n `� '� JDATE/ �`i �� COL. 20 /388 <br />