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i <br /> CPG #. TO: ICE OF REVENUE AND RECOVERY •ACCOUNT TRANSMITTALCOPY <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 TAT CYCLE I STATUS DATE BMd CBM INT MONTHLY PAY AMT PYMT PROB <br /> 13222 HAZMAT 7/15/09 <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 2007 - 2009 Annual <br /> Hmmp Fee $720.00 <br /> 2 Chems @ $15.00 <br /> Each Year $90.00 <br /> 10% Late Charge $81.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $915.00 <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 /> PERFORMANCE MACHINE <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 11667 PALM LN UNIT F MANTECA CA 95336 <br /> S-POUS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PERFORMANCE MACHINE <br /> EMPLOYER STREET 1 CITY ST ZIP CODE <br /> 11667 PALM LN UNIT F MANTECA ;�� � c t CA 95336 <br /> PREPARED BY CHECKED BY - DATE COL 20 (3ias) <br />