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TO: 0 CE OF REVENUE AND RECOVERY <br /> CPG # . C O <br /> �— ACCOUNT TRANSMITTAL V <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> WOODBRIDGE PIZZERIA <br /> C/O NAME GUARANTOR SSN <br /> ELIZABETH CASTILLO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-603-1528 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1110 W. KETTLEMAN LN. #2 LODI CA 95240 209-603-1528 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMCl CBMCI INT MONTHLY PAY AMTPYMT I PROS <br /> 14363 HAZMAT t I I 1 <br /> 7/15/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> Qosa <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY =NO <br /> EMPLOYER NAME EMPLOYER PHON <br /> WOODBRIDGE PIZZERIA 209-603-1528 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1110 W KETTLEMAN LN #48 LODI CA 95240 <br /> SP6NSP.- CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WOODBRIDGE PIZZERIA 209-603-1528 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1110 W KETTLEMA LN #48 LODI I CA 95240 <br /> REPARED BY CHECKED BY JDATE COL. 2C (areal <br />