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CPG # TO: DICE OF REVENUE AND RECOVERY O py <br /> � ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. lAl. CI REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BAJA FRESH MEXICAN GRILL#185 <br /> C/O NAME GUARANTOR SSN <br /> MARTIN LOPEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5350 PACIFIC AVE #J-2STOCKTON CA 95207 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. BILL bTAT CYCLE STATUS DATE BM CBMd INd MONTHLY PAY AMT <br /> 14048HAZMAT 1.11/,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 CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2006-2009 Hmmp <br /> Annual Fee $960.00 <br /> 1 Chem @ $15.00 <br /> Each Year $60.00 <br /> 10% Late Charge $102.00 <br /> TOTAL $1122.00 <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 /> BAJA FRESH MEXICAN GRILL#185(CLOSED) <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 5350 PACIFIC AVE#J-2 STOCKTON CA 95207 <br /> SF8i1,SE- CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO I AUTO LIC NO <br /> I I <br /> EMPLOYER NAME I EMPLOYER PHONE NO <br /> BAJA FRESH MEXICAN GRILL#185(CLOSED) <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 5350 PACIFIC AVE#J-2 ST C 452 CA 95207 <br /> REPARED B CHECKED BY IDATE lO COL 20(3M) <br />