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CPG # TO: ICE OF REVENUE AND RECOVERY <br /> 6 ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL copy 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TACOS Y MARISCOS SINALOA <br /> C/O NAME GUARANTOR SSN <br /> LUIS LOPEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4127 WEST LN STOCKTON CA 95204 209-774-6063 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> N/A N/A N/A N/A 209-774-6063 <br /> USER REFERENCE NO. IBILL kTAT ICYCLE ISTATUS DATE BMCBM INT MONTHLY PAY AMT PYMT PROB <br /> 14123 HAZMAT 11/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> ICU <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 2009 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $25.50 <br /> TOTAL $280.50 <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 /> TACOS Y MARISCOS SINALOA 209-774-6063 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4127 WEST LN STOCKTON CA 95204 <br /> SPOUS& 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 /> TACOS Y MARISCOS SINALOA 209-774-6063 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4127 WEST LN STOCKY NCA 5204 <br /> REPARED BYI CHECKED BY = �,G� --/c,,'/.r, DATE �- COL. 20 (MB) <br />