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CPG # TO: nvFICE OF REVENUE AND RECOVERY COPY <br /> %./ ACCOUNT TRANSMITTALACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE F LAST - AKA - FIRS! MI TITLE <br /> FOREST LAKE GOLF COURSE <br /> C/O NAMEGUARANTOR SSN <br /> MARGARET J RING <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 209-369-5457 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 209-369-7464 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMI INT MONTHLY PAY AMT I YM <br /> 5689 HAZMAT3/20/11 MDATF <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. TION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $315.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 1 1 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $31.50 J <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $395.50 <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 /> FOREST LAKE GOLF COURSE 209-369-5457 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 <br /> 8f4MM CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FOREST LAKE GOLF COURSE 209-369-5457 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2450 E WOO DSO RD A P - CA 95220-9646 <br /> PREPARED BY CHECKED BY DATE &/00 // COL. 20 (3M) <br />