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CPG # T0: ICE REVENUE AND RECOVERY • COPY <br /> � <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNTNO. DEPT. NO. REFERRAL <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 /> il I <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 CBMd INT MONTHLY PAY AMT PYMT PNA n <br /> ATI <br /> 13884 HAZMAT 11/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> E23 <br /> STOP MED REC NO CHARGE <br /> DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 026000.0 2005 - 2009 Hmmp <br /> Annual Fee $1200.00 <br /> 1 Chem @ $15.00 <br /> Each Year $75.00 <br /> 10% Late Charge $127.50 <br /> TOTAL $1402.50 <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 CA 95205 <br /> SPOUSE. 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 /> MENDOZA'S AUTO BODY& PAINT <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2538 N WEST LN #19-20 TOCK ON CA 95205 <br /> REPARED BY CHECKED BY - G[' u DATE � � COL 20 (3188) <br />