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CPG # T0: FILE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL PY <br /> ACCOUNT NO. DEPT.NO. REFERRAL DATE CO <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> PCI-PAINTING <br /> C/O NAME GUARANTOR SSN <br /> PCI -------- rL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 SAN JUAN AVE STOCKTON CA 95203 209-460-0498 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 SAN JUAN AVE STOCKTON CA 95203 209-460-0498 <br /> USER REFERENCE NO. BILL STAI CYCLE STATUS DATE BMd CBMC INT MONTHLY PAY AMT <br /> 13313 HAZMAT 3115108 <br /> CHARGES <br /> LAST - RECIPIENT FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE <br /> NO DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $25.50 <br /> State Surcharge Fee $24.00 <br /> TOTAL $304.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 SAN JUAN AVE STOCKTON CA 95203 <br /> $F61ffiB CO—OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 SAN JUAN AVE STOCKTON CA 95203 <br /> PREPARED BY //� A CHECKED BY DATE // � coy. 20 ares <br /> C / � �3 4� <br />