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CPG # TO: "-PICE OF REVENUE AND RECOVERY C <br /> O py ACCOUNT TRANSMITTAL 1 <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> DATE <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SAFEWAY STORE#2707 <br /> C/O NAME GUARANTOR SSN <br /> SAFEWAY INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> SAFEWAY STORE#2707 P.O. BOX 9070 BLDG 6000 PLEASANTON CA 94588 925-469-7306 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 5918 STONERIDGE MALL RD PLEASANTON CA 94588 925-469-7306 <br /> USER REFERENCE NO. I BILL STA CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT <br /> IF DATE TERM DATE <br /> 12132 HAZMAT 819104 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTDOB USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NO <br /> 230 026000.0 Hmmp 10% Late Charge $10.00 <br /> TOTAL $10.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAFEWAY STORE#2707 925-469-7306 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 6425 N PACIFIC AVE STOCKTON CA 95207 <br /> OPeUGH CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. I DOB I DR LIC NO I AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> SAFEWAY STORE#2707 925-469-7306 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 6425 N PACIFIC AVE STOCKTON >� CA 95207 <br /> PREPARED BY CHECKED BY JDATE 'OL. " 'W <br /> / O <br />