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TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL [py <br /> ACCOUNOFIRST <br /> � REFERRAL �..L • <br /> 0 <br /> LAST - GUARMI TITLE LAST - AKA - FIRST MI TITLE <br /> FOREST LAKC/O NAMEGUARANTOR SSN <br /> MARGARET J <br /> MAILING STREET CITY ST ZIPCODE 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 kAT CYCLE STATUS DATE BMd CBM INT MONTHLY PAY AMT YMT LTP <br /> PR <br /> 5689 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1.3/20/10 <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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $315.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $31.50 <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 195220-9646 <br /> S-POU&& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB I DR LIC NO I AUTO LIC NO <br /> I 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 WOODSON RD ACAMP CA 95220-9646 <br /> REPARED BY CHECKED BY JDATE a J/ COL. 20 (3IBB) <br />