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-CPG # ' TO: FICE OF REVENUE AND RECOVERY <br /> y/ ACCOUNT TRANSMITTAL <br /> RM <br /> DEPT.NO. REFERRAL <br /> 026000.0 8/8/03 <br /> R - FIRST MI TITLE LAST - AKA - FIRST <br /> MI TITLE <br /> L INSTITUTION <br /> GUARANTOR SSNCTIONS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> DEUEL VOCATIONAL INSTITUTION P.O. BOX 400 TRACY CA 95378-0400 209-835-4141 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 942883 SACRAMENTO CA 94283-0001 916-445-7688 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMTHouVTTm <br /> 4655 HAZMAT 7/27/03 <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. CHARGE <br /> NO DESCRIPTION AMOUNT DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2003 Hmmp Annual Fee $240.00 <br /> 30 Chems @ $15.00 $450.00 <br /> I I- <br /> 10% Late Charge $69.00 <br /> TOTAL $759.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CRY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DEUEL VOCATIONAL INSTITUTION 209-835-4141 X5090 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 23500 KASSON RD TRACY CA 95376 <br /> 6PeF39E CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DEUEL VOCATIONAL INSTITUTION 209-835-4141 X5090 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 23500 KASSONRD TRACY CA 95376 <br /> PREPARED BY CHECKED BY JDATE &x&03 COL. 20 Iyee <br />