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CPG # `I0: ICE OF REVENUE AND RECOVERY r <br /> 0 ACCOUNT TRANSMITTAL <br /> o <br /> ACCOUNT NO. DEPT. NO. REFERRnA'rC c ( py <br /> AL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MOUNTAIN MIKE'S PIZZAI <br /> CIO NAME GUARANTOR SSN <br /> PAUL MANN <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> MOUNTAIN MIKE'S PIZZAI 1589 W EL CAMINO#101 AVE SACRAMENTO CA 95833 209-957-1400 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2971 CHATEAU MONTELENA WAY SACRAMENTO CA 95834 209-957-1400 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PROB <br /> Q1 IP nATr- <br /> 13674 HAZMAT 11/15/09 <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 Kin DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT, NO, DESCRIPTION AMOUNT <br /> 230 026000.0 2008 Hmmp Annual Fee $240.00 <br /> 1 Chem @ $15.00 $15.00 <br /> 10% Late Charge $25.50 <br /> TOTAL $280.50 <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 /> MOUNTAIN MIKE'S PIZZAI 209-957-1400 <br /> EMPLOYER STREET CITY 9CA <br /> ZIP CODE <br /> 5066 N WEST LN STE E STOCKTON 95210 <br /> ria CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I I I I I I I I I I --I I A- I I F I:dl I I I I <br /> I I_ <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MOUNTAIN MIKE'S PIZZAI 209-957-1400 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> �5066 N WEST LN STE E TOC T N CA 95210 <br /> REPARED B CHECKED BY DATE j 6 p COI. 20 (3l68I <br />