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CPG # TO: 'ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ' /�70 py <br /> ACCOUNT NO. DEPT.NO. REFERRA �'\(�\:J• <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ORIENTAL BUFFET <br /> C/O NAME GUARANTOR SSN <br /> XIU RONG DOING <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4704 PACIFIC AVE STOCKTON CA 95207 9164127888 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4704 PACIFIC AVE STOCKTON CA 95207 9164127888 <br /> USER REFERENCE NO. IBILLI STA CYCLEI STATUS DATE BM CBMCJ INT I MONTHLY PAY AMT <br /> nATF <br /> 12954 HAZMAT 2/27/08 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTnnR 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. <br /> NO DESCRIPTION AMOUNT <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 <br /> State Service Fee $24.00 <br /> I I r1L IL I I <br /> TOTAL $279.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ORIENTAL BUFFET 9164127888 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4704 PACIFIC AVE STOCKTON CA 95207 <br /> 9PeUOB CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ORIENTAL BUFFET 9164127888 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 4704 PACIFIC AVE STOCKTON CA 95207 <br /> PREPARED BY I CHECKED BY �.. DATE 'd. OB COL. 20 1 8 <br />