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CPG # TO: "ICE OF REVENUE AND RECOVERY <br /> _ lb.. ACCOUNT TRANSMITTAL +� COPY <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CLEMENTS ROAD WINERY <br /> C/O NAME GUARANTOR SSN <br /> JEFF LEBARD <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> CLEMENTS ROAD WINERY P.O. BOX 2818 YOUNTVILLE CA 94599 209-887-3819 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 7415 ST. HELENA HWY YOUNTVILLE CA 94599 209-887-3819 <br /> USER REFERENCE NO. IBILL TAT CYCLE STATUS DATEI BmC1 CBMd INT MONTHLY PAY AMT YM PR <br /> OB <br /> 13302 HAZMAT 3/15/09 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $28.50 <br /> State Surcharge Fee $24.00 <br /> TOTAL $337.50 <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 /> CLEMENTS ROAD WINERY 209-887-3819 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 11989N CLEMENTS RD LINDEN CA 95236 <br /> SP4WJS& 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 /> CLEMENTS ROAD WINERY 209-887-3819 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 11989N CLEMENTS RD LINDEN CA 95236 <br /> PREPARED BY CHECKED BY jDATE Z.� Q� COL 20(3M) <br /> 4 � <br />