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CPE d TO: •ICE OF REVENUE AND RECOVERY Copy <br /> ACCOUNT TRANSMITTALACCOUNT NO. DEPT.NO. REFERRA026000.0 L <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ROOKIES GRILL <br /> C/O NAME GUARANTOR SSN <br /> TOM NICKEL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1251 W YOSEMITE AVE MANTECA CA 95336 209-249-6019 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1251 E.YOSEMITE AVE MANTECA CA 95336 209-249-6019 <br /> USER REFERENCE NO. I BILL Sjd CYCLE STATUS DATE BM CBMC INT I MONTHLY PAY AMT <br /> 12846 HAZMIAT I I I I I I I I I I I I I j 3/15/07 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED RED NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2007 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 Each $15.00 <br /> 10% Late Charge $25.50 1 1 1 1 <br /> State Surcharge Fee $24.00 <br /> �a <br /> TOTAL $304.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROOKIES GRILL 209-249-6019 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1251 W YOSEMITE AVE MANTECA CA 95336 <br /> SPeUSH'' CO-OWNER <br /> LAST FIRSTMI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ROOKIES GRILL 209-249-6019 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1251 W YOSEMITE AVE MANTECA CA 95336 <br /> PREPARED BY I CHECKED BY-lot DATE I COL. 20 yea <br />