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CPG # TO: --FICE OF REVENUE AND RECOVERY ^ 0 �� <br /> - ...- ACCOUNT TRANSMITTALFER ..,R v'J_ <br /> ACCOUNT NO. DEPT. NO. RERAL '\/(\/ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JIM &MIKE'S PERFORMANCE AUTO <br /> C/O NAME GUARANTOR SSN <br /> RUBEN RUBALCAVA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> JIM & MIKE'S PERFORMANCE AUTO 820 S CALIFORNIA ST STOCKTON CA 95206 209-507-2799 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1822 NIGHTINGALE AVE STOCKTON CA 95205 209-507-2799 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PR B <br /> 14153 HAZMAT 11/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> r _ <br /> CHARGE DEPT, NO. DESCRIPTION AMOUNT 3HARGE D NO. C40 AMOUNT <br /> mn <br /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $8.50 <br /> TOTAL $93.50 <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 /> JIM & MIKE'S PERFORMANCE AUTO 209-507-2799 <br /> EMPLOYER STREET F CITY ST ZIP CODE <br /> 820 S AMERICAN ST STOCKTON CA 95206 <br /> SFAFISE_ CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JIM &MIKE'S PERFORMANCE AUTO 209-507-2799 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 820 S AMERICANST TO KT CA 95206 <br /> REPARED BY CHECKED BY DATE 114110 COL 20 (3j <br /> J <br />