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CPG # _ TO: C--"ICE OF REVENUE AND RECOVERY COP <br /> MACCOUNT TRANSMITTAL V <br /> ACCOUNT NO, DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PAYLESS SMOG <br /> C/O NAME GUARANTOR SSN <br /> MARIA SERRATO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 3227 E MAIN ST ASTOCKTON CA 95205 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM C8M INT MONTHLY PAY AMT <br /> PYMT PR B <br /> 13061 HAZMAT <br /> 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 /> 230 026000.0 2006 - 2009 Hmmp <br /> Annual Fee $280.00 <br /> 1 Chem @ $15.00 <br /> Each Year $60.00 <br /> 10% Late Charge $34.00 <br /> TOTAL $374.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY STT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PAYLESS SMOG <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3227 E MAIN ST A STOCKTON CA 95205 <br /> SPOU68 CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO I AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PAYLESS SMOG <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3227 E MAIN ST A STOCKTON - CA 95205 <br /> REPARED B CHECKED BY _ DATE - /� coL. zo (3j <br />