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• CPG 4 TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> Copy <br /> ACCOUNT NO. DEPTNO. I DATREFERRAL <br /> 0420001 <br /> LAST - GUARANTOR FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CENTURY AUTO COLLISION <br /> C/O NAME GUARANTOR SSN <br /> NORMA CORTES It <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. BILL STA CYCLEI STATUS DATE BM CBMCJ INT IMONTHLY PAY AMTYMI <br /> 7700 HAZMAT I I I I I I I I I I I I I j 8/15/03 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTDOR T 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 /> 380 0420001 1999-2003 Hmmp Annual <br /> Fee(5 Years Total) $1200.00 <br /> 1 Chem @ $15.00 Each <br /> Per Year $75.00 <br /> 10% Late Charge $127.50 <br /> State Service Fee $17.50 <br /> TOTAL $1420.00 <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 JST ZIP CODE <br /> 3128 E FREMONT ST STOCKTON CA 95205 <br /> 3PAHSB CO-OWNER <br /> LAST FIRST MI TITLE 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 ZIP CODE <br /> 3128 E FREMONT ST STOCKTON CA 1 95205 <br /> PREPARED BYG" ,9�• / I CHECKED BY ��� DATE yg 63 coy. 20 wee <br />