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CPG #i TO: -VICE OF REVENUE AND RECOVERY <br /> �., ACCOUNT TRANSMITTAL Copy ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> FOREST LAKE GOLF COURSE <br /> C/O NAME GUARANTOR SSN <br /> MARGARET J RING <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 209-369-5457 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 209-369-7464 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PR 8 <br /> 5689 HAZMAT 1.3/15/09 <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 CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $30.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $354.00 <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 /> FOREST LAKE GOLF COURSE 209-369-5457 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2450 E WOODSON RD ACAMPO CA 95220-9646 <br /> SPOUS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FOREST LAKE GOLF COURSE 209-369-5457 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2450 E WOODSON RD ACAM PO CA 952 0-9646 <br /> REPARED BY I CHECKED BY JDATE a Coy. 20 13ieel <br />