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rRAMIREZ <br /> TO: ICE OF REVENUE AND RECOVERY •ACCOUNT TRANSMITTALCOPY <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> AUTOMOTIVE <br /> NAME GUARANTOR SSN <br /> RAMIREZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 811 N SACRAMENTO ST LODI CA 95240 209-367-4332 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 315 S STOCKTON ST LODI CA 95240 209-367-4385 <br /> 05 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMTDATE <br /> 6584 HAZMAT 3/15/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: gAE <br /> START STOP MED REC NOARGE DEPT.NO. DESCRIPTNT CHARGE DEPT.NO. DESCRIPTION AMOUNTNO230 026000.0 2008 Hmmp An .00 <br /> 3 Chems @ $15.00 Each $45.00 <br /> 10% Late Charge $28.50 <br /> State Service Fee $24.00 <br /> Sm Hz Gen <5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> F, 1+1 1 1 1 . . . ---- <br /> TOTAL $763.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAMIREZ AUTOMOTIVE 209-367-4332 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 811 N SACRAMENTO ST LODI CA 95240 <br /> 9£9i-90 CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAMIREZ AUTOMOTIVE 209-367-4332 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 811 N SACRAMENTO ST LODI 1 Cq . 95240 <br /> REPARED BY CHECKED B JJDATE �� �,p. COL. 20 r3/e8 <br />