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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL nopy 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SIMPLE DESIGNS MFG (CLOSED) <br /> C/O NAME GUARANTOR SSN <br /> SIMPLE DESIGNS MFG <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> SIMPLE DESIGNS MFG (CLOSED)20495 TETON AVE TUALATIN OR 97062 209-464-1106 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 20495 SW TETON AVE TUALATIN OR 97062 503-692-6964 <br /> USER REFERENCE NO. IBILL TAT ICYCLE ISTATUS DATEI BMI CBMI INT MONTHLY PAY AMT I n, <br /> PYMT IF nATFB <br /> 9551 HAZMAT 1.3/1,5/09 <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 CHARGEMC) DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Annual Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $321.00 <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 /> SIMPLE DESIGNS MFG (CLOSED) 209-464-1106 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> -d <br /> 1627 ARMY CT STE 1 STOCKTON CA 95206 <br /> S-POUS& 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 /> SIMPLE DESIGNS MFG (CLOSED) 209-464-1106 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 1627 ARMY CT STE 1 STOCKTON CA 95206 <br /> REPARED BY CHECKED BY JDATE �/' ,, COL. 20Q <br /> /S< <br />