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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL topy ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE <br /> LAST - AKA - FIRST MI TITLE <br /> A C TRANSMISSION <br /> C/O NAME GUARANTOR SSN <br /> SERGIO MORALES <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> A C TRANSMISSION 2088 N LARA LN TRACY CA 95376 209-469-0587 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TRACY CA 95376 209-914-4994 <br /> 2088 LARA LN <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM (-BMC INT MONTHLY PAY AMT <br /> PYMT PROB <br /> 3/20/10 <br /> 10854 HAZMAT <br /> CHARGES <br /> LAST - RECIPIENT - FIRST <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPT. NODESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> . <br /> 230 026000.0 2010 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> CITY ST ZIP CODE <br /> PRIOR STREET <br /> EMPLOYER PHONE NO <br /> EMPLOYER NAME <br /> A C TRANSMISSION 209-469-0587 <br /> CITY ST ZIP CODE <br /> EMPLOYER STREET <br /> CA 95205 <br /> 4035 N WILSON WAY#8 STOCKTON <br /> S?Ai3S CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. <br /> DOB DR LIC NO AUTO LIC NO <br /> I 1 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A C TRANSMISSION 209-469-0587 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4035 N WILSON WAY#8 STOCKY N CA 95205 <br /> REPARED BY <br /> CHECKED BY DATE y`�3 ra COL. 20 (3M) <br />