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CPG k TO: OFFICE OF THE COLLECTOF <br /> �- <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. DATE <br /> 04 0 01 1 5 1 <br /> LAST - GUARANTOR - FIRST <br /> MI TITLE LAST - AKA - FIRST MI TITLE <br /> I I I <br /> Thorgei iii , 'SIM I <br /> GUARANTOR SSN <br /> C/O NAME <br /> Jim Thorpe 1 1 1 1 <br /> CITY SST ZIP CODE AREA PHONE NO <br /> MAILING STREET . <br /> 3 1o41i1 1 M 9 <br /> CITY ST ZIP CODE AREA PHONE NO. <br /> RESIDENCE STREET <br /> iQ?lT0 T t y ooil PROS <br /> PVMT <br /> USER REFERENCE NO. BILLSTA CLCy-E STATUS DATE MC MB INT MONTHLY PAY PMT pUE DATE TERM DATE <br /> �apkT ReToyjl I I I I I I <br /> CHARGES <br /> LAST - RECIPIENT FIRST <br /> MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> - ❑OR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> 2 9 <br /> _.ARG DESCRIPTION AMOUNT MNROGE DEPT NO DESCRIPTION <br /> NO <br /> 380 0410001 1 Tank Removal 26 :50 <br /> I I I I 1 1 1 1 1 1 1 I I ( I I I I <br /> 380 04100011 i P nal 5 `5 <br /> I I I I I I I I l l l l j l I I 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> I I I I I I I I I I I I I I <br /> 1 1 1 1 1 1 1 1 1 1 1 1 1I t I I I 1 1 1 1 1 1 <br /> I I I I I I 1 1 1 1 1 1 1 <br /> TOTAL 32 07 <br /> GUARANTOR <br /> DOB OR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> 1 1 1 1 1 1 1 I I I I I I 1 1 1 1 1 1 I I I I I I I I <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 t OR LIC NO AUTO LIC NO <br /> ------------ <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> PREPARED BY C ED DATE/ 1 <br /> "'✓� J ® COL. 2013/851 <br />