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CPG # TO: O CE OF REVENUE AND RECOVERY • <br /> ACCOUNT TRANSMITTAL �O �...�` — <br /> ACCOUNT NO. DEPT. NO. REFERRAL ��uu„rr�//)\l�U(// <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> QDOBA <br /> C/O NAME GUARANTOR SSN <br /> DELIGHTFUL DINING -ABE ALAZADO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> QDOBA 3001 S LAVA RIDGE CT STE 340 ROSEVILLE CA 95661-2838 209-6096609 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2551 DOUGLAS BLVD#120 ROSEVILLE CA 95661 916-786-6191 <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DAFE1 BMI CBM INT MONTHLY PAY AMT I P MT PROB <br /> 13186 HAZMAT 3/15/09 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLEJ RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Kin <br /> 230 026000.0 2009 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 l <br /> 10% Late Charge $25.50 <br /> State Surcharge Fee $24.00 <br /> n <br /> u <br /> TOTAL $304.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONENO <br /> QDOBA 209-6096609 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 10940 TRINITY PKWY H STOCKTON CA 95219 <br /> S-POV" 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 /> QDOBA 209-6096609 <br /> EMPLOYER STREET CITY STV;95219 <br /> ODE <br /> 10940 TRINITY PKWY H STOCKTON CREPARED BY CHECKED B DATE Coy. 20 (3188) <br />