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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL COP <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PERFORMANCE MACHINE <br /> C/O NAME GUARANTOR SSN <br /> WALT OTT <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 11667 PALM LN UNIT FMANTECA CA 95336 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-484-7987 <br /> USER REFERENCE NO. BILL bTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT TTPAKAnATP <br /> PROS <br /> 13222 HAZMAT 3/20/10 <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 /> CHARGE DEPT.NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Kin <br /> 230 026000.0 2010 Hazmat Fee $270.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $27.00 <br /> TOTAL $346.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PERFORMANCE MACHINE <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 11667 PALM LN UNIT F MANTECA CA 95336 <br /> S�ABST} CO—OWNER <br /> AST FIRST MI TITLESOfSECLNO : DOB DR LIC NO AUTO LIC NO <br /> I 1 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PERFORMANCE MACHINE <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 11667 PALM LN UNIT F NT A CA 95336 <br /> PREPARED BY CHECKED BY DATE �f /� COL. 90 (11j. <br />