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CPG # TO: ---VICE OF REVENUE AND RECOVERY C 0 �� <br /> ACCOUNT TRANSMITTAL ,,,.. <br /> ACCOUNT NO. DEPT.NO, REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CHARLIE'S AUTO PARTS&HARDWARE <br /> C/O NAME GUARANTOR SSN <br /> STANLEY POWERS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4515 E MAIN ST STOCKTON CA 95215 209-466-0841 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONENO. <br /> 10736 ELKHORN DR STOCKTON CA 95209 209-957-6229 <br /> MT p7olr_ <br /> USER REFERENCE NO. I BILL STAI CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> 12030 HAZMAT I I I I I I I I I I I I I I I I I I I 19/7/04 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2003-2004 Hmmp <br /> Annual Fee $480.00 <br /> 2003-2004 2 Chems @ <br /> $15.00 Each Year $60.00 'x, <br /> 10% Late Charge $54.00 <br /> State Service Fee $24.00 i <br /> TOTAL $618.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CHARLIE'S AUTO PARTS& HARDWARE 209-466-0841 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4515 E MAIN ST STOCKTON CA 95215 <br /> eENeUSS CO—OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CHARLIE'S AUTO PARTS&HARDWARE 209-466-0841 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4515 E MAIN ST STOCKTOIN CA 1 95215 <br /> PREPARED BY,/ , / I CHECKED B JDATE /O , O '/ Co_ 20 (aee <br />