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CPG # TO: ICE OF REVENUE AND RECOVERY 0 Q <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL U <br /> nATF <br /> 026000.0 8/8/03 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> WILD ROSE VINEYARDS <br /> C/O NAME GUARANTOR SSN <br /> R. LAWSON ENTERPRISES <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> WILD ROSE VINEYARDS P.O. BOX 298 VICTOR CA 95253 209-339-0102 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8751 E HWY 12 VICTOR CA 95253 209-339-0102 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> 9798 HAZMAT 7/27/03 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> nQR <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. CHARGE <br /> NO DESCRIPTION AMOUNT DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2003 Hmmp Annual Fee $240.00 Previously <br /> 6 Chems @ $15.00 Each $90.00 a erre : <br /> 10% Late Charge $33.00 3/21/03 - Unpaid <br /> TOTAL $363.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WILD ROSE VINEYARDS 209-339-0102 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8751 E HWY 12 VICTOR CA 95253 <br /> 5�6t3'33r} CO—OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WILD ROSE VINEYARDS 209-339-0102 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8751 E HWY 12 VICTOR CA 95253 <br /> PREPARED BY ( �,: CHECKED V IDATE 6i8'03 COL 20 lyes <br />