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CPG # TO: ICE OF REVENUE AND RECOVERY ACCOUNT TRANSMITTALCopy ACCOUNT NO. DEPT.NO. REFERRAL <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 /> 1738 S UNION ST STOCKTON CA 95206 209-464-2583 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8602 TAM OSHANTER ST STOCKTON CA 95210 209-952-3538 <br /> USER REFERENCE NO. I BILL STA CYCLE STATUS DATE BM CBMC INT I MONTHLY PAY AMT <br /> DATE TERM DATE <br /> 6575 HAZMAT j 3/21/04 <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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2004 Hmmp Annual Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Service Fee $24.00 <br /> TOTAL $321.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> TONY'S CUSTOM CONCRETE 209-464-2583 <br /> EMPLOYER STREET CITY TZIP ODE <br /> 1738 S UNION ST STOCKTON CA 95206 <br /> ePeUSE 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 BY, gL� /�._ CHECKED BY DATE (o 1 7 C(l COL 20 (3188 <br />