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CPG # TO: ^ICE OF REVENUE AND RECOVERY <br /> .► ACCOUNT TRANSMITTAL .1 <br /> ACCOUNT NO. DEPT. NO. REFERRAL O 1p <br /> 026000.0 1 C <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> J&H MARINE <br /> C/O NAME GUARANTOR SSN <br /> ERIC KOSTER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 345 N YOSEMITE ST STOCKTON CA 95203 209-951-0283 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 345 N YOSEMITE ST STOCKTON CA 95203 209-951-0283 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT PFM <br /> 13692 HAZMAT I 1 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1.3/1,5/09 <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 2005-2009 Hmmp <br /> Annual Fee $350.00 <br /> 1 Chem @ $15.00 <br /> Each Year $75.00 <br /> 2005-2009 10% <br /> Late Charge $42.50 <br /> State Surcharge Fee $24.00 <br /> TOTAL $491.50 <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 /> J&H MARINE 209-951-0283 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 345 N YOSEMITE ST STOCKTON CA 95203 <br /> S?9U&& CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> J&H MARINE 209-951-0283 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 345 N YOSEMITE ST STOCKTO CA 95203 <br /> REPARED BY CHECKED BY DATE A� COL. 20 (3M)) <br />