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CPG # I TO: WCE OF REVENUE AND RECOVERY • COPY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TONY'S CUSTOM CONCRETE <br /> C/O NAME GUARANTOR SSN <br /> TONY RAMONETT <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TONY'S CUSTOM CONCRETE P.O. BOX 66029 STOCKTON CA 95206-0929 209-464-2583 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 688 S. PERSHING AVE. STOCKTON CA 95203 209-937-0633 <br /> USER REFERENCE NO. I BILL STA CYCLE STATUS DATE BM CBMC INT I MONTHLY PAY AMT <br /> 6575 HAZMAT I I I I I I I I I I I I I I I I I I 1 3/15/07 <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 DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2007 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 Each $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 /> TONY'S CUSTOM CONCRETE 209-464-2583 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1738 S UNION ST STOCKTON CA 95206 <br /> &POUBc CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TONY'S CUSTOM CONCRETE 209-464-2583 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1738 S UNION ST STOCKTON CA 95206 <br /> PREPARED 13�, CHECKED BY DATE ! COL 20 (388 <br /> t <br />