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CPG' # TO: OFFICE OF REVENUE AND RECOVERY C:z� (Dpoy ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NCS. <br /> REFERRAL ..I <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SUPER SMOG & REPAIR <br /> C/O NAME GUARANTOR SSNtjL <br /> ROBERT VASQUEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 511 N AMERICAN ST STOCKTON CA 95202 916-261-5094 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 849 SHELLWOOD WAY SACRAMENTO CA 95831 916-261-5094 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT MT PROBI <br /> 13397 HAZMAT I 1 11 1 1 1 1 1 1 1 1 1 1 1 1 1.4/1.5/11 <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 /> Kin <br /> 230 042000.0 2011 Hazmat Fee $100.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $10.00 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380042000.0 380 042000.0 <br /> TOTAL $585.00 <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 /> SUPER SMOG & REPAIR 916-261-5094 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AMERICAN ST STOCKTON CA 95202 <br /> CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SUPER SMOG & REPAIR 916-261-5094 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 511 N AMERICAN ST STOCKT N CA 95202 <br /> REPARED BY CHECKED BYDATE i� /� coy 2o caree7 <br />