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4 TO: OFFICE OF REVENUE& RECOVERY <br /> CPG: _ ACCOUNT TRANSMITTAL <br /> ACCOUNT NO DEPT NO REFERRAL DATE <br /> X1 8 A.Xv 1 0420000 17 r;951 <br /> LAST--OUARANTOR• FIRST MI LAST ARa FIRST MI <br /> Evans lRobert <br /> CIO NAME SSN/FED# DR. LIC.NO. <br /> Elon Inc <br /> MAILING STREET CITY STI ZIP AREA PHONE# <br /> 891 Monticello Ln Manteca CA 95336 209 481-5180 <br /> FACILITYADDRESS 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 /> °NGE <br /> NO DEPT NO DESCRIPTION AMOUNT GE °HNO 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 ISTIZIP <br /> PREPARED BY: DATE: <br /> REVIEWED BY: DATE: C <br />