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CPG # TO: r "ICE OF REVENUE AND RECOVERY <br /> y ACCOUNT TRANSMITTAL lw P <br /> n�Tl CO <br /> � nACCOUNT NO. DEPT. NO. REFERR \h(J/(/ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ULLOA'S TOW&AUTO REPAIR 1 11 11 l 11 11 <br /> C/O NAME GUARANTOR SSN <br /> ULLOA'S TOW&AUTO REPAIR <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 S WILSON WAY STE CSTOCKTON CA 95205 209-943-0588 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-943-0588 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMd INT MONTHLY PAY AMT I PYMT PROB, <br /> 12529 HAZMAT 11/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> nQu <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> mn <br /> 230 026000.0 2005 - 2009 Hmmp <br /> Annual Fee $350.00 <br /> 2 Chems @ $15.00 <br /> Each Year $150.00 <br /> 10% Late Charge $50.00 <br /> TOTAL $550.00 <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 /> ULLOA'S TOW&AUTO REPAIR 209-943-0588 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 S WILSON WAY STE C STOCKTON CA 95205 <br /> SAAN49 CO-OWNER <br /> ST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ULLOA'S TOW&AUTO REPAIR 209-943-0588 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 S WILSON WAY STE C TO TON CA 95205 <br /> REPARED BY CHECKED BY _ DATE ` / COL. zo (IT-) <br />