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CPG # TO: ICE OF REVENUE AND RECOVERY <br /> It ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> nATF: c(opy <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE I LAST - AKA - FIRST MI TITLE <br /> GCS WESTERN POWER&EQUIP <br /> CIO NAME GUARANTORSSN <br /> GCS WESTERN POWER&EQUIP <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 1041 S PERSHING AVE STOCKTON CA 95206 209-464-9600 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 6407-B NE 117TH AVE VANCOUVER WA 98662 360-253-2346 <br /> USER REFERENCE NO. BILL STA CYCLE STATUS DATE BM C13MCI INT MONTHLY PAY AMT <br /> 8383 HAZMAT 9/7/04 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTnnR USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE <br /> NO DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Hmmp Additional Chem <br /> 1 ® $15.00 $15.00 <br /> 10% Late Charge $1 .50 <br /> TOTAL $16.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> I I I I I 1 -1 1 1 1 H <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GCS WESTERN POWER&EQUIP 209-464-9600 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1041 S PERSHING AVE STOCKTON I CA 95206 <br /> &PeUSE CO-OWNER <br /> LAST FIRST Mi TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> GCS WESTERN POWER&EQUIP 209-464-9600 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1041 S PERSHING AVE STOCKTON CA 95206 <br /> PREPARED BY / <br /> CHECKED 8Y DATE /O <br /> C.y u x 4f f cot. 20 a ca <br /> v 7 <br />