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CPG' # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL (cOpy <br /> ACCOUNT NO. DEPT.NO. REFERRAL u �u( <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PERFORMANCE MACHINE 1 11 11 <br /> C/O NAME GUARANTOR SSN <br /> WALT OTT 4 4 ' <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 /> PRUb <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM iNd MONTHLY PAY AMT <br /> 13222 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 13/15/12 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> pip <br /> 230 042000.0 2012 Hazmat Fee $270.00 8q 1 P43009.01 <br /> 30 1 014290010 1 Hazmat Penalty Fee $27.00 pBq04 00 .0 <br /> p8q q42900,0 State Surcharge Fee $24.00 p8q4 00 .0 <br /> p8q 014290010 Electronic Surcharge $25.00 p8q <br /> 80 1 014290010 8 4 3009-01 <br /> 80 11 042 00 1 p8q <br /> 80 1 0 2 00.p I �8q 11 P43009.01 <br /> TOTAL $346.00 <br /> GUARANTOR <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <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 /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PERFORMANCE MACHINE <br /> EMPLOYERSTREET CITY ST 71P CODE <br /> 11667 PALM LN UNIT F MANT�ECA CA 95336 <br /> :L <br /> / - ,•% /,/ ! CHECKED BY IDATE COL. zo Iaiae) <br />