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CPG # :, TO: r ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY ACCOUNT NO. DEPT.NO. REFERRAL026000 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> LEXINGTON <br /> CIO NAME GUARANTOR SSN <br /> LEXINGTONd, <br /> h MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> LEXINGTON 3300#500 UNIVERSITY DRIVE CORAL SPRINGS FL 33065 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. BILL STAT CYCLE STATUS DATE BMC CBM IN MONTHLY PAY AMT PYMT PROB <br /> 14169 HAZMAT i 1/15/09 <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 /> I I I F a i I I I I I I 1 1 —7 <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2007 - 2009 Hmmp <br /> Annual Fee .$720.00 <br /> 1 Chem @ $15.00 <br /> Each Year $45.00 <br /> 10% Late Charge $76.50 <br /> TOTAL $841.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC.NO_ <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE-NO <br /> LEXINGTON <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 110 W FREMONT ST STOCKTON CA 95202 <br /> SPOUSE CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> LEXINGTON <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 110 W FREMONT ST STO TO CA 9/5292 <br /> REPARED BY CHECKED.BY DATE / ` /� COL. 20 {3788) <br /> ' I <br />