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CPG' # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COPY <br /> ACCOUNTNO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> THIEL'S TIRE PRO&AUTO REPAIR <br /> C/O NAME GUARANTOR SSN <br /> RJDM CORP <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1131 HOLLY DR TRACY CA 95376 209-765-7060 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1131 HOLLY DRIVE TRACY CA 95376 209-835-6900 <br /> USER REFERENCE NO. IBILL TAT CYCLE STATUS DATE SMI CBMI IN MONTHLY PAY AMT <br /> TPPDA DAT-F, <br /> 12573 HAZMAT 1 . 3/15/12 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> WR idn <br /> 230 042000.0 2012 Hazmat Fee $130.00 lq 1 P43009.01 <br /> 30 1 0142,10010 1 Hazmat Penalty Fee $13.00 38q1043009.01 <br /> P89 I q42900rl) I State Surcharge Fee $24.00 8q 1 P43009.01 <br /> p8q 1 04290010 Electronic Surcharge Fee $25.00 38q <br /> 1 1 <br /> S o 2000 1 400 .0 <br /> 1 11 <br /> 8 02000 1 38q400 .0 <br /> 80 1 002qOO.p A p8q4 00 .0 <br /> TOTAL $192.00 <br /> GUARANTOR <br /> nnpi DR I Ir NO <br /> PRIOR STREET CITY qT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> THIEL'S TIRE PRO&AUTO REPAIR 209-765-7060 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1131 HOLLY DR TRACY CA 1 95376 <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> THIEL'S TIRE PRO&AUTO REPAIR 209-765-7060 <br /> EMPLOYER STREET CITY ST 71P com: <br /> 1131 HOLLY DR TRACY CA 95376 <br /> NECKED BY IDATE COL. N (WW) <br />