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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL O � /7 <br /> IL1fL_JJ�� <br /> ACCOUNT NO. DEPT. NU. I mc <br /> REFERRAL \U�/ <br /> 026000.0 <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 BM CBM INT MONTHLY PAY AMT PYMT PROB <br /> 13884 HAZMAT 3/20/10 <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 /> Kin <br /> 230 026000.0 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> TOTAL $329.50 <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 /> MENDOZA'S AUTO BODY& PAINT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2538 N WEST LN#19-20 STOCKTON <br /> SCA 95205 <br /> �9HSE- CO—OWNER <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 CITY ST ZIP CODE <br /> 2538 N WEST LN#19-20TOCK4N CA 95205 <br /> PREPARED BY I CHECKED BY DATE ,5/ 3/10 coL W(vee) <br />