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CPG # TO: ICE OF REVENUE AND RECOVERY <br /> IV ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL lam`..;;✓✓^ V <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MOKELUMNE RIVER FISH HATCHERY <br /> C/O NAME GUARANTOR SSN <br /> EAST BAY MUNICIPAL UTILITIES DIST <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> MOKELUMNE RIVER FISH HATCHERY P.O. BOX 158 CLEMENTS CA 95227 209-759-3383 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 20445 OAKLAND CA 20445 510-287-0407 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBM INT MONTHLY PAY AMT I P MT PR <br /> 6940 HAZMAT I 1 11 11 11 1 1 1 1 1 1 1 1 1 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 /> 6 Chems @ $15.00 Each $90.00 <br /> 10% Late Charge $33.00 \ <br /> State Service Fee $24.00 er <br /> Sm Hw Gen<5 Tons/yr $213.00 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $813.00 <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 /> MOKELUMNE RIVER FISH HATCHERY 209-759-3383 <br /> EMPLOYER STREET CITU ST ZIP CODE <br /> 25800 N MCINTIRE RD CLEMENTS CA 95227 <br /> SPOUSE- CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MOKELUMNE RIVER FISH HATCHERY 209-759-3383 <br /> EMPLOYER STREET CITY ST ZIP CODE a_ <br /> 25800 N MCINTIRE RD CLEMENTS CA 1 95227 <br /> PREPARED BY 1 CHECKED BY ' JDATE O 9 COL 20(3=) <br />