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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL 1 0 pyACCOUNT 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 NAMEGUARANTOR SSN <br /> DAN MILLS& MIKE VALDEZ <br /> MAILING STREET - CITY ST ZIP CODE AREA PHONE NO. <br /> COPE MFG CO P.O. BOX 2660 LODI CA 95241-2660 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 /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYM B <br /> 8700 HAZMAT A 1.3/20/10 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START I STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 'In230 026000.0 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> TOTAL $362.50 <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 /> COPE MFG CO 209-334-1999 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 20400 N KENNEFICK RD ACAMPO CA 95220 <br /> SPOUf1b- 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 /> COPE MFG CO 209-334-1999 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 20400 N KENNEF K R AC PO CA 95220 <br /> PREPARED BY CHECKED BY ATE ��' �L'J COL. W MIMI <br />