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CPG # TO: VICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> DATE <br /> 026000.0 8/8/03 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> A-1 AUTO SERVICE <br /> C/O NAME GUARANTOR SSN <br /> BALJIT GILL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1850 N MAIN ST MANTECA CA 95336 408-210-4580 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1962 EVERGLADES DR MILPITAS CA 95035 408-945-1313 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BMj CBMC INT I MONTHLY PAY AMTPRO <br /> 10139 HAZMAT I I I I I I I I I I I I 1 11 7/27/03 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> nnq <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE <br /> NO DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. I\ DESCRIPTION AMOUNT <br /> NO <br /> 230 026000.0 2003 Hmmp Annual Fee $70.00 Previous Referral <br /> 2 Chems @ $15.00 Each $30.00 - Unpaid <br /> 10% Late Charge $10.00 <br /> t <br /> TOTAL $110.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A-1 AUTO SERVICE 408-210-4580 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1850 N MAIN ST MANTECA CA 95336 <br /> SPOUSE CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> A-1 AUTO SERVICE 408-210-4580 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1850 N MAIN ST MANTECA CA 95336 <br /> PREPARECHECKEp,BY . �= DATE <br /> 8/8/03 COL. 20 (18e <br />