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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> CO <br /> ,�.�� n <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> ''unJl\VU/ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SUPER SMOG &REPAIR <br /> C/O NAME GUARANTOR SSN <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 ZIPCODE AREA PHONE NO. <br /> 849 SHELLWOOD WAY SACRAMENTO CA 95831 916-261-5094 <br /> USER REFERENCE NO. IBILL TAT CYCLE STATUS DATE 13Md CBM INT MONTHLY PAY AMT MT F I PROB <br /> 13397 HAZMAT 1. <br /> 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Addition Of 1 Chemical $15.00 <br /> Hazmat Penalty Fee $1.50 <br /> TOTAL $16.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <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 9521 <br /> S-POU49 CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 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 STOCKTO CA 95202 <br /> REPARED BY CHECKED BY JDATE /,I -/0 COL. W (alae) <br />