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CPG # TO: �'ICE <br /> REVENUE RECOVERY <br /> ACCOUNT TRANSMITTAL C (DMDY <br /> CCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 n,m <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SAFE DRAIN INC <br /> C/O NAME GUARANTOR SSN <br /> SAFE DRAIN INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> SAFE DRAIN INC 612516 SAN JOSE CA 95161 408-738-6600 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 408-738-6600 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PY B <br /> 13659 HAZMAT 11 1 1 1 1 1 1 1 1 1 1.7/1 <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 2008& 2009 Annual <br /> Hmmp Fee $480.00 <br /> 2 Chems @ $15.00 <br /> Each Year $60.00 <br /> 10% Late Charge $54.00 Aw <br /> State Surcharge Fee $24.00 1911 <br /> I+ I I 1 11 <br /> TOTAL $618.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAFE DRAIN INC 408-738-6600 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 119 VAL DERVIN PKWY#1 STOCKTON CA 95206 <br /> SPAB69 CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAFE DRAIN INC 408-738-6600 <br /> EMPLOYER STREET CITY - ST ZIP CODE <br /> 119 VAL DERVIN PKWY#1 STOCKTON .z, -Et, :fy �, CA 1 95206 <br /> REPARED BY I CHECKED BY JDATE COL. 2a (3M)) <br /> L <br />