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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NZ5' REFERRAL V <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> FAIRMONT REHABILITATION HOSPITAL <br /> C/O NAME GUARANTOR SSN <br /> LODI SKILLED NURSING SVC INC <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 950 S FAIRMONT AVE LODI CA 95240 209-368-0693 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 950 S. FAIRMONT AVENUE LODI CA 95240 209-368-0693 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBM INT MONTHLY PAY AMT PYMT Pq <br /> 5269 HAZMAT 3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> TOTAL $329.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FAIRMONT REHABILITATION HOSPITAL 209-368-0693 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 950S FAIRMONT AVE LODI CA 95240 <br /> SPAUSS CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FAIRMONT REHABILITATION HOSPITAL 209-368-0693 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 950 S FAIRMONT AVE DI CA 95240 <br /> PREPARED BY I CHECKED BY ATE ,�/ �3 /a CAL. 10 NIMR) <br />