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CPG # _ TO: OFFICE OF THE COLLEC� <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO.i DEPT. NO. DATE <br /> 94100 '2 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> i5 LESS VII <br /> C/O NAMEdba GUARANTOR SSN <br /> I I IC I�IN� CNpfI <br /> MAILING STREET CITY ST ZIP CODE AR�PHONE <br /> BO 60 Lodil Ca 95 41i <br /> RESIDENCE STREET site address CITY ST ZIP CODE JAREA PHO NENO. <br /> Moll, Ii , y 9 A P a 2011111 <br /> PYMT PftOB <br /> USER REFERENCE NO. BILLSTA CLE STATUS DATE BMC MBC INT MONTHLY PAY AMT DUE GATE TERM DATE <br /> CALKII9 1 1 1 <br /> CHARGES <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> LAST - RECIPIENT - FIRST DOB <br /> I I I I <br /> SERVICE DATE: ' DATE OF <br /> START STOP MED REC NO CHARGE Underground Storage Tank fees & penalties <br /> cHARG DESCRIPTION AMOUNT HNOGE DEPT NO DESCRIPTION <br /> NO pp <br /> 1988 Fees 12pW M (� <br /> I 1988 Penalty I of \ I <br /> I • 11 1992 Fees <br /> I ' 1992 Penalty 1 1 O <br /> �� <br /> i <br /> T o <br /> TOTAL I I <br /> GUARANTOR t <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> I I I I I I I I I I I I I I I I I I I I I I 1 1 1 1 1 1 1 I I I I I I I I I <br /> SPOUSE <br /> LAST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> i l 1 't i1 I I <br /> EMPLOYER NAME JEMPLOYER PHONE NO <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> PRELELPARED BY CHECKED BY DATE <br /> ® COL. 20 (3/85) <br />