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OPG # T0: =^FICE OF REVENUE AND RECOVERY COPY� <br /> , ACCOUNT TRANSMITTAL ..r <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GARLIC BROTHERS RESTAURANT& <br /> C/O NAME GUARANTOR SSN <br /> GREGORY RISSO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 6629 EMBARCADERO STOCKTON CA 95219 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMd INT MONTHLY PAY AMT PYMT PROS <br /> 13848 HAZMAT 11/15/09 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> mr)230 026000.0 2008 - 2009 Hmmp <br /> Annual Fee $480.00 <br /> 1 Chem @ $15.00 <br /> Each Year $30.00 <br /> 10% Late Charge $51.00 <br /> TOTAL $561.00 <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 /> GARLIC BROTHERS RESTAURANT& BAR <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 6629 EMBARCADERO STOCKTON CA 95219 <br /> SPOUSE- 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 /> GARLIC BROTHERS RESTAURANT& BAR <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 6629 EMBARCADERO S OC N CA 95219 <br /> REPARED BY CHECKED BY, JDATE C//,7 COL. 20 (3iBB) <br /> 6 <br />