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CPG # TO: L01FICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL py <br /> 4 ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST GUARANTOR - FIRST MI TITLE LAST AKA - FIRST MI TITLE <br /> J-R TRUCK&TRAILER REPAIR <br /> C/O NAME GUARANTOR 5SN <br /> MALLS RICKY INN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> J-R TRUCK&TRAILER REPAIR 3833 DUCK CREEK DR STOCKTON CA 95216 209-462-2599 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 9326 EAGLE POINT LANE STOCKTON CA. 95210 209-401-7334 <br /> USER REFERENCE NO. BILL STAI CYCLEI STATUS DATEI BMd CBMCI INT I MONTHLY PAY AMT <br /> 12947 HAZMAT 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTnnrt 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 /> NONO <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $30.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $354.00 <br /> GUARANWR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITYS7 ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> J-R TRUCK&TRAILER REPAIR 209-462-2599 <br /> EMPLOYER STREET .CITY ' ST ZIP CODE <br /> 3833 DUCK CREEK DR A STOCKTON CA 95215 <br /> epebvm CO-Of+ti1mR <br /> LAST FIRST - MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> J-R TRUCK&TRAILER REPAIR 209-462-2599 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3833 DUCK CREEK DR A STOCKTON. CA 95215 <br /> PREPARED 8Y CHECKED B IDATEI <br /> ���� 00L. 20 r�ras <br />