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TO: OFFICE OF REVENUE & RECOVERY <br /> CPG: ACCOUNT TRANSMITTAL <br /> ACCOUNT NO DEPT NO REFERRAL DATE <br /> 1 12 33 <br /> 0420000 <br /> LAST- -GUARANTOR. FIRST MI LAST AKA FIRST MI <br /> Evans, Robert <br /> CIO NAME SSNI FED# DR.LIC.NO. <br /> Elon Inc <br /> MAILING ADDRESS CITY ST ZIP AREA PHONE# <br /> 22865 Henry Rd Escalon CA 95320 (209)481-5180 <br /> FACILITY ADDRESS CITY ST <br /> 17333 S Comconex Rd Manteca CA 95336 1 (209)481-3442 <br /> USER REFERENCE NO <br /> Invoice #248646 <br /> COMMENTS: <br /> SERVICE DATE: <br /> START: 1130114 STOP: 1130114 <br /> CHARGE CHARGE <br /> NO DEPT NO DESCRIPTION AMOUNT NO DEPT NO DESCRIPTION AMOUNT <br /> Inv#248646 <br /> 380 0420000 SM HW Gen Permit 213.00 <br /> AST Facility Fee 675.00 <br /> State Surchg Fee 35.00 <br /> Permit Fee Penalty 888.00 <br /> TOTAL 1,811.00 <br /> EMPLOYER NAMEISOURCE OF INCOME: EMPLOYER PHONE# <br /> EMPLOYER STREET CITY ST ZIP <br /> PREPARED BY: DATE: <br /> REVIEWED BY: DATE: <br />