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CPG '# TO: OFFICE OF REVENUE AND RECOVERY • Fly <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. Na REFERRAL 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 BMd CBM INT MONTHLY PAY AMT PROBI <br /> Tr <br /> 14153 HAZMAT 3/20/10 <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 /> 230 026000.0 2010 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 1 law <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <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 CITY ST ZIP CODE <br /> 820 S AMERICAN ST STOCKTON CA 95206 <br /> SPOU469 CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> 1 1 <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 STOC TO CA 95206 <br /> PREPARED BY CHECKED BY DATE /� coy. n (alae) <br />