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CPG # T0: CCE OF REVENUE AND RECOVERY • Copy <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPTNO. REFERRAL <br /> . <br /> nATF <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> INDUSTRIAL DESIGN&FAB <br /> C/O NAME GUARANTOR SSN <br /> LAURIE CORNELL/JERRY HICKS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> INDUSTRIAL DESIGN&FAB P.O. BOX 268 STOCKTON CA 95201 209-937-9128 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3825 E WOODWARD AVE / 6210 MCCAULEY RD.VALLEY MANTECA / CA. 95336/95252 209-937-9128 <br /> PHO <br /> USER REFERENCE NO. I BILL STA CYCLE STATUS DATE BMd CBMC INT I MONTHLY PAY AMT <br /> 10937 HAZMIAT I I I I I I I I I I I I I I I I I I 1 11 <br /> 3/6/04 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DOB <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> NONO <br /> 230 026000.0 2004 Hmmp Annual Fee $240.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> 10% Late Charge $27.00 <br /> State Service Fee $24.00 <br /> TOTAL $321.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY STZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> INDUSTRIAL DESIGN&FAB 209-937-9128 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 802 S SAN JOAQUIN ST STOCKTON CA 95206 <br /> 6f4UxSB CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> INDUSTRIAL DESIGN&FAB 209-937-9128 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 802 S SAN JOAQUIN ST STOCKTON CA 95206 <br /> PREPARED By <br /> ` // CHECKED BY DATE 5!�/0�/ cOL. 20 (yee <br />