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CPG # TO: C TCE OF REVENUE AND RECOVERY COPY <br /> L ACCOUNT TRANSMITTAL *014ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> COPE MFG CO <br /> C/O NAME GUARANTOR SSN <br /> DAN MILLS&MIKE VALDEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 20400 N KENNEFICK RD ACAMPO CA 95220 209-334-1999 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. DRAWER 2660 LODI CA 95241-2660 209-334-1999 <br /> PHUB <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE 134 CBMC INT MONTHLY PAY AMTATE <br /> 8700 HAZMAT 3/6/04 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCEnnR <br /> 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 /> NOmn <br /> 230 1 026000.0 2004 Hmmp Annual Fee $240.00 <br /> 4 Chems @ $15.00 Each $60.00 <br /> 10% Late Charge $30.00 <br /> State Service Fee $24.00 <br /> ma Ims <br /> TOTAL $354.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> COPE MFG CO 209-334-1999 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 20400 N KENNEFICK RD ACAMPO CA 95220 <br /> 8RIE)U3H CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> COPE MFG CO 209-334-1999 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 20400 N KENNEFICK RD ACAMPO CA 95220 <br /> PREPARED BY- / CHECKED BY �P _ JDATE /�/� COL. 20 f3/88 <br />