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CPG # T0: OFFICE OFC REVENUE AND RECOVERY �r,� ��� <br /> ACCOUNT TRANSMITTAL (\/+\\/wr1//\/� ',Un�) <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ROCKY'S RESTAURANT <br /> C/O NAME GUARANTOR SSN <br /> BARRY BENIGNO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ROCKY'S RESTAURANT P.O. BOX 2601 LODI CA 95241 209-369-1973 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1121 WCHURCHILLST STOCKTON CA 95207 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMC INT MONTHLY PAY AMT I PYMT PROS <br /> 9760 HAZMAT 1.3/20/1,0 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT 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 /> 380 042000 0 2011 Hazmat Fee $85.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $8.50 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROCKY'S RESTAURANT 209-369-1973 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 14659 N THORNTON RD LODI CA 95242 <br /> SA08SE- CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROCKY'S RESTAURANT 209-369-1973 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 14659 N THORNTON RD LO CA 95242 <br /> REPARED BY CHECKED BY ,,, D TE /� `/ coy. 20 c31ael <br />