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CPG q TO: C -CE OF REVENUE AND RECOVERY ACCOUNTTRANSMITTALCOPY ACCOUNT NO. DEPT.NO. REFERRAL <br /> QATF <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CENTURY AUTO COLLISION <br /> C/O NAME GUARANTOR SSN <br /> NORMA CORTES H 11 <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3128 E FREMONT ST STOCKTON CA 95205 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 745 W HARDING WAY STOCKTON CA 95204 209-430-7302 <br /> USER REFERENCE NO, BILLISTAI CYCLE STATUS DATE BM CBMC INT I MONTHLY PAY AMT jPYMT <br /> IF DATE TERM DATE <br /> 7700 HAZMAT 1/24/05 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <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 2005 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $25.50 <br /> State Service Fee $24.00 <br /> Sm Hw Gen <5 Tons/yr $200.00 <br /> Permit Fee Penalty $200.00 <br /> TOTAL $704.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CENTURY AUTO COLLISION <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3128 E FREMONT ST STOCKTON CA 95205 <br /> 3�PAF38•E CO—OWNER <br /> LAST FIRST MI TITLEJ SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CENTURY AUTO COLLISION <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 3128 E FREMONT ST STOCKTON I CA 95205 <br /> PREPARED BY CHECKEDB DATE COL. 20 Brea <br /> ? /� o5 <br />