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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL 10 C O py <br /> ACCOUNT NO. DEPT.NO. REFERR026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MENDOZA'S AUTO BODY& PAINT <br /> C/O NAME GUARANTOR SSN <br /> JUAN MENDOZA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2538 N WEST LN #19-20STOCKTON CA 95205 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INJ MONTHLY PAY AMT <br /> 13884 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1. 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NR Hm <br /> 230 042000.0 2012 Hazmat Fee $255.00 p8q <br /> 1 1 <br /> 30 014290010 1 Hazmat Penalty Fee $25.50 p1q1143009.01 <br /> �8q q42900rO I State Surcharge Fee $24.00 p8q4 00 .0 <br /> p8q 1 014290010 Electronic Surcharge $25.00 P89 <br /> 80 1 0I42Q0010 I P89 <br /> 80 1 014 2 q0010 I �8q 1, P43009.0, <br /> 80 1 0 2 00.p _j p8q 11 P43009.01 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> PRIOR STREET STZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MENDOZA'S AUTO BODY&PAINT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2538 N WEST LN#19-20 STOCKTON CA 95205 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MENDOZA'S AUTO BODY&PAINT <br /> EMPLOYER STREET <br /> 2538 N WEST LN#19-2�STO TON CA 95205 <br /> �RFPARFn By ..r CHECKED BY IDATE COL. 20 (W88) <br />