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TO: OFFICE OF REVENUE & RECOVERY <br /> crG: ACCOUNT TRANSMITTAL <br /> ACCOUNT NO DEPT NO REFERRAL DATE ' <br /> 2;-77 33 S' 0420000 // zl & <br /> LAST- -GUARANTOR- FIRST MI -LAS A" FIRST MI <br /> Evans I Robert <br /> C/O NAME SSNI FED# DR.LIC.NO. <br /> Elon Inc <br /> MAILING STREET CITY ST ZIP AREA PHONE# <br /> 891 Monticello Ln Manteca CA 95336 (209 481-5180 <br /> FACILITY ADDRESS I CITY ST. ZIP <br /> 17333 S Comconex Rd Manteca CA 95336 209 481-3442 <br /> USER REFERENCE NO <br /> Inv#211380 <br /> COMMENTS: <br /> - <br /> SERVICE DATE: <br /> START STOP <br /> 1128/2011 1/2812011 <br /> cHNO DEPT NO DESCRIPTION AMOUNT c NO E DEPT NO DESCRIPTION AMOUNT <br /> Inv#211380 <br /> 380 0420000 SM HW Gen Permit 213.00 <br /> 380 0420000 AST Facility Permit 675.00 <br /> 380 0420000 State Surcharge Fee 24.00 <br /> 380 042000 0 Electronic Reporting 25.00 <br /> 380 0420000 Permit Fee Penalty 213.00 <br /> 380 0420000 Permit Fee Penalty 675.00 <br /> TOTALI 1,825.00 <br /> EMPLOYER NAME/SOURCE OF INCOME: EMPLOYER PHONE# <br /> EMPLOYER STREET CITY ST ZIP <br /> PREPARED BY: DATE: S� a— <br /> REVIEWED BY: DATE: / . <br />