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CPG # - TO: 'ICE OF REVENUE AND RECOVERY <br /> "O. ACCOUNT TRANSMITTAL C <br /> OPY ACCOUNT NO. DEPT. NO. REFERR <br /> 026000.0 nAT� <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> JAMESJORDAN <br /> C/O NAME GUARANTOR SSN <br /> JAMES LJORDAN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONENO. <br /> JAMES JORDAN 45 W WORTH ST STOCKTON CA. 95206 209-430-4473 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-430-4473 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT I n, <br /> PYMT <br /> 13276 HAZMAT 1.7/1 <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 /> 230 026000.0 2009 Annual Hmmp Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Surcharge Fee $24.00 <br /> TOTAL $321.00 <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 /> JAMES JORDAN 209-430-4473 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 45 W WORTH ST STOCKTON CA 95206 <br /> SPQVri CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> JAMES JORDAN 209-430-4473 <br /> EMPLOYER STREET CITY I ST ZIP CODE <br /> 45 W WORTH ST STOCKTON k`_ 6y CA 95206 <br /> REPAIRED BY I CHECKED BY JDATE COL. zo (area) <br /> ,r <br />