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CPC&,9 • TO: OFFICE OF THE COLLEC t <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> DATE <br /> 0410001 3 29 !Q <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> Henderson Rick <br /> I I I I I I I LI I <br /> C/O NAME GUARANTOR SSN <br /> Golden West Environmental <br /> I I I I I I I I I I <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. Box 1236 Brentwood CA 94513 1634 <br /> I I I I I I I I I I I I I 1 1 1 1 1 1 I I i <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> I I I ILI I 11 1 1 11 1 1 1 1 <br /> USER REFERENCE NO. BILLSTA CLE STATUS DATE MC MC INT MONTHLY PAY AMT PYMT PROS TER <br /> DUE DATE TERM DATE _ <br /> Inspection & Review I ' <br /> I I I I 1 1 1 1 1 1 I I i 1 I <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REF ERENCENO/NARRATIVE <br /> DOB <br /> I I I I <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE Penalty Cha Cs Only - SBAASFprI <br /> '�*�! , �.rmy 04 Support <br /> 7 1 i9 hru 9/2/92 Mort ci+w <br /> HNOG DESCRIPTION AMOUNT HNROGE DEPT NO DESCRIPTION <br /> 380410001 Inspection Penally, 1 1 1 76 80 <br /> I I I I <br /> I I 1 1 1 1 1 1 I I I I I I <br /> I I I I I I f I l I l l j l I I 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> I I I I I I I I I I 1 1 1 I I <br /> 114I I I A <br /> I I I I I I 1 1 1 1 1 1 1 <br /> TOTAL <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 /> 1 1 1 1 1 1 1 I I I I I 1 1 1 1 1 1 I I I I I I I I I I I I <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> I I I I I I I I I I I I I I I I I I I I I I 1 1 1 1 1 1 1 I I I I I I I I I <br /> SPOUSE <br /> LAST FIRST MI TITLE SOC SEC NO. DOB OR LIC NO AUTO LIC NO <br /> I I I I I I I I I I I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> PREPARED BY CHECKED BY DATE <br /> ® C.L. 20 (3/85) <br />