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CPG # T0: O^ 'ICE REVENUE AND RECOVERY P MACCC OUNT TRANSMITTALCO <br /> \'U1/ <br /> ACCOUNT NO. DEPT. NO. QATP <br /> REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE - <br /> PACIFIC SUPPLY <br /> C/O NAME GUARANTORSSN <br /> PACIFIC COAST SUPPLY, LLC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PACIFIC SUPPLY 3965 N WILCOX RD STOCKTON CA. 95215 916-631-6570 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4290 ROSEVILLE ROAD NORTH CA 95660 916-971-2301 <br /> USER REFERENCE NO. BILL kAT CYCLE STATUS DATE BMd CSMd INT MONTHLY PAY AMT I <br /> PYMT PROB <br /> 5403 HAZMAT 11 1 1 1 1 1 1 1 1 1 1.3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DLTE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPTmr) .NO. DESCRIPTION AMOUNT HARGE DEPT. ESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $85.00 ment -$57.50 <br /> Used Oil Only<5tons/yr $54.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Fee Penalty $8.50 <br /> Debit Adjustment $85.00 <br /> Correction To A Charge -$139.00 0 <br /> 'ror L $85.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PACIFIC SUPPLY 916-631-6570 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3965 N WILCOX RD STOCKTON CA 95215 <br /> SPOUrig CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PACIFIC SUPPLY 916-631-6570 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3965 N WILCOX RD STOCKTO CA 95215 <br /> PREPARED BY CHECKED BY _ DATE p _44_/ COQ. 20 (alae) <br />