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CPG`# TO: OFFICE OF REVENUE AND RECOVERY <br /> Ah ACCOUNT TRANSMITTAL <br /> REFERRAL copy <br /> ACCOUNTNO. DEPT. NU <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> WEST LANE MUFFLER & <br /> C/O NAME GUARANTOR SSN <br /> QUYEN TRAN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> WEST LANE MUFFLER & PERFORMANCE 3805 N WEST LANE STOCKTON CA 95204 2094818496 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3626 MASSIMO CIR STOCKTON CA 95212 2094818496 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATBM CBMC INT MONTHLY PAY AMT PYMT RNA nATF <br /> 13885 HAZMAT <br /> E <br /> 3/20/1 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 /> 380 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $25.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <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 /> WEST LANE MUFFLER & PERFORMANCE 2094818496 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3805 N WEST LN C-2 STOCKTON CA 95204 <br /> SPOUSE CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WEST LANE MUFFLER &PERFORMANCE 2094818496 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3805 N WEST LN C-2 S CI( N r CA 95204 <br /> REPARED BY I CHECKED BY DATE J „/��r COL 20 (3/88) <br />