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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL O Py <br /> DEPT. Nr <br /> ACCOUNT NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PAYLESS SMOG <br /> C/O NAME IGUARANTOR 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 ff!F!!!Ej <br /> BM INT MONTHLY PAY AMT <br /> M B <br /> 13061 HAZMAT 3/20/10 <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 /> CHARGEDEPT. NO. DESCRIPTION AMOUNT HARGE DEUNT <br /> PT. NO. DESCRIPTION AMO <br /> 230 026000.0 2010 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <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 I ZIP CODE <br /> 3227 E MAIN ST A STOCKTON CA 95205 <br /> SPOUSE CO—OWNER <br /> ST FIRST MI SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> i I 1 <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 IS CHECKED 8Y DATE y�a3`l COL. 20 (3IBB7 <br />