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To: RAY From: T. Simmons 11-07-11 3:09pm p. 3 of 9 <br />f <br />TO. <br />CPG: > ) 7 <br />-FICE OF REVENUE & RECOVERY <br />ACCOUNT TRANSMITTAL <br />1 \ <br />j <br />ACCOUNT NO DEPT NO <br />:rte ..042000 0 <br />REFERRAL DATE <br />a <br />LAST - -GUARANTOR- ' FIRST <br />MI <br />LAST AKA <br />FIRST <br />MI <br />Farias <br />Ramon- <br />cio NAME <br />SSN! FED # <br />DR. LIG. NO. <br />Farias Body & Paint <br />MAILING STREET <br />CITY <br />ST <br />ZIP <br />AREA PHONE # <br />1807 E Cherokee Rd Ste 1 & 2 <br />Stockton <br />CA <br />95205 <br />(209) 346-2141 <br />FACILITY ADDRESS <br />CITY <br />ST <br />ZIP <br />1807 E Cherokee Rd Ste 1 & 2 <br />Stockton <br />I CA <br />95205 <br />(209) 570-2081 <br />SERVICE DATE: <br />START STOP <br />2/1/2010 211/2010 <br />COMMENTS: Additional Address: 4609 Dorset 1, Stockton, CA 95207 <br />CHARGE DEPT NO DESCRIPTION <br />NQ <br />AMOUNT <br />CHARGE <br />NO DEPT NO <br />NO <br />DESCRIPTION <br />AMOUNT <br />380 0420000 Inv #200902 <br />Sm Hw Permit Fee <br />213.00 <br />State Surcharge Fee <br />24.00 <br />Electronic Rptg Sur <br />25.00 <br />Permit Pen Fee <br />213.00 <br />TOTAL <br />475.00 <br />EMPLOYER NAMEISOURCE OF INCOME: <br />EMPLOYER PHONE # <br />EMPLOYER STREET <br />CITY <br />ST <br />ZIP <br />PREPARED BY: <br />DATE: LL' <br />REVIEWED BY: �/! /j ((J� <br />DATE: f 7- {� <br />