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TO: OFFICE OF REVENUE& RECOVERY <br /> CPG: _ ACCOUNT TRANSMITTAL <br /> ACCOUNT NO DEPT NO REFERRAL DATE <br /> I S 9-2-0 1 0420000 <br /> LAST--GUARANTOR- FIRST MI LAST AKA FIRST MI <br /> Evans Robert <br /> CIO NAME SSN/FED# DR.LIC.NO. <br /> Elon Inc 68-0246286 <br /> MAILING STREET CITY ST ZIP AREA PHONE# <br /> 891 Monticello Ln Manteca CA 95336 209 481-5180 <br /> FACILITYADDRESS i CITY ST ZIP <br /> 17333 S Comconex Rd Manteca CA 95336 (209) 481-3442 <br /> COMMENTS: <br /> SERVICE DATE: <br /> START STOP <br /> 2/1/2010 211/2010 <br /> cN GE <br /> NO <br /> DEPT NO DESCRIPTION AMOUNT °H O DEPT NO DESCRIPTION AMOUNT <br /> 380 0420000 Inv#198374 <br /> Sm Hw Gen Per 213.00 <br /> AST Fac Per Fee 337.00 <br /> State Surchg Fee 24.00 <br /> Electronic Reptg Fee 25.00 <br /> Permit Pen Fee 550.00 <br /> TOTAL 1,149.00 <br /> EMPLOYER NAME/SOURCE OF INCOME: EMPLOYER PHONE# <br /> EMPLOYERSTREET CITY ISTI ZIP <br /> PREPARED BY: DATE: (5-1.;7-Ig p <br /> REVIEWED BY: DATE: C <br />