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CP® p • TOt OFFICE OF THE COLLE4 <br /> ACCOUNT TRANSMITTAL <br /> ° ACCOUNT NO. DEPT. NO. <br /> DAT <br /> I <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> INFflLp I I I I I I I I MARr <br /> C/O NAME GUARANTOR SSN <br /> I I I <br /> MAILING STREET CITY ST I ZIP CODE AREA PHONE NO. <br /> PO BOX 516 RO DBR,IDGE C 9525 StRR. 20 ;334 ; 2141 <br /> RESIDENCE STREET CITY ST ZIP CODE JAREA PHONE NO. <br /> ,107, p tsChopliT 0 <br /> USER REFERENCE NO. SILLSTA CLE STATUS DATE M M INT MONTHLY PAY AMT DUE DATE TERM DATE <br /> I I <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RE 01018 NT USER REFERENCE NO/NARRATIVE <br /> I <br /> SERVICE DATE: oArEoriUNDERGROUND STORAGE TANK FEES LOCATED at. 107 N SCHOOL ST <br /> START STOP Ll MED REC NO CHARGE FEES WERE NEVER PAID ON TANK #5 FOR YEARS 1986 & 1987 <br /> 2ND CONTACT PERSON - JOSEPH NEWFIELD (Same Address) <br /> HARG DESCRIPTION AMOUNTHNROGE <br /> NO DEPT NO DESCRIPTION <br /> EE k <br /> I I I #5 TANK I I I Sol198b IANK #5 <br /> Aq I I <br /> 1 1 1 1 1 1 1 1ruprHARGE FEE i I 1 961 bo I I I I I I I I I <br /> I I 1 1 1 1 1 1 987 TANK #5 1 • <br /> 10SURE FEE 1901 00 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> I I I II <br /> i <br /> I I I 1 1 <br /> 1 1 <br /> 1 I I I I I I <br /> TOTAL 186 °llfl <br /> GUARANTOR tw <br /> DOB OR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> I <br /> I I I I I I I I I I I I I I I I I • <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 11 I I I I I I I I I I I I I II I I I II I 1 1 1 1 1 1 1 1 � <br /> SPOUSE <br /> LAST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> I <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> t <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> P RE BY CHECKED BY D T .7 <br /> ® COL. 2013/85) <br />