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CPG # TO: '9'ICE OF REVENUE AND RECOVERY d <br /> . ACCOUNT TRANSMITTAL '1j0 py <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SUSY'S MEXICAN FOOD <br /> C/O NAME GUARANTOR SSN <br /> FRANCISCO PADILLA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 120 W HARDING WAY STOCKTON CA 95204 209-463-0360 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3756 BROOK VALLEY CIR STOCKTON CA 95219 209-956-3105 <br /> USER REFERENCE NO. BILL TAT CYCLE I STATUS DATE BMd CBMd INT MONTHLY PAY AMT I YMT PROB <br /> 14214 HAZMAT 1.11/15/09 <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 /> mn <br /> 230 026000.0 2009 Hmmp Late Charge $127.50 <br /> TOTAL $127.50 <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 /> SUSY'S MEXICAN FOOD 209-463-0360 <br /> EMPLOYER STREET T CITY ST ZIP CODE <br /> 120 W HARDING WAY STOCKTON CA 95204 <br /> SJLGU9& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO I AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SUSY'S MEXICAN FOOD 209-463-0360 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 120 W HARDINGAY. Sj. C CA 95204 <br /> REPARED BY i CHECKED BY DATE z �e COL. zo(areal <br />