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CPG # TO: nFFICE OF REVENUE AND RECOVERY O PQ Y <br /> ACCOUNT TRANSMITTAL 'I1l�,�J' <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. JBILL kTAT CYCLE STATUS DATE BMd CBM INTI MONTHLY PAY AMT <br /> 13061 HAZMAT <br /> 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGEDEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $85.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 oa2000.o Electronic Surcharge $25.00 <br /> Sao oa2DDo.0 Hazmat Penalty Fee $8.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $142.50 <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 /> PAYLESS SMOG <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3227 E MAIN ST A STOCKTON CA 95205 <br /> S-POUS& CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO 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 /> REPA RED BY CHECKED BY DATE v // ppb. W(S) <br />