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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> in ACCOUNT TRANSMITTAL ACCOUNT NO. 0260000DEPT. NO. ngTr <br /> REFERRALCopyLAST - GUARANTOR - FIRST MI TITLE LAST - AKA - IIRSST MI TITLE <br /> MUFFLER MAN (LODI) <br /> C/O NAME GUARANTOR SSN <br /> JIM LOOCK/LOOCK LIVING TRUST <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 827 N SACRAMENTO ST LODI CA 95240-1252 209 333 2556 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 423 1/2 POPLAR ST LODI CA 95240 209-333-2556 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBMI INT MONTHLY PAYAMT PYMT PROS <br /> 7626 HAZMAT <br /> 3/20/10 <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 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> ti <br /> r <br /> TOTAL P$329 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MUFFLER MAN (LODI) 209 333 2556 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 827 N SACRAMENTO ST LODI CA 95240-1252 <br /> SPAUS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO, I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MUFFLER MAN (LODI) 209 333 2556 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 827 N SACRAMENTO S L DI CA 95240-1252 <br /> PREPARED BY CHECKED BV oy. zo f3�1 <br />