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CPG # TO: ICE OF REVENUE AND RECOVERY �� O D <br /> ACCOUNT TRANSMITTAL D0 <br /> p\�// <br /> ACCOUNT NO. DEPT.NO. REFERRAL U <br /> DATE <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> AIRGAS-NO.CALIF.-NEVADA <br /> C/O NAME GUARANTOR SSN <br /> AIRGAS-NO. CALIF.-NEVADA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> AIRGAS-NO.CALIF.-NEVADA P.O.BOX 19255 SACRAMENTO CA 95819 209-993-8653 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 19255 SACRAMENTO CA 95819 209-931-2470 <br /> USER REFERENCE NO. BILL Sj�j CYCLE STATUS DATE BM CBMC INT I MONTHLY PAY AMT PYMT <br /> Q(IF DATE TERM DATE <br /> 12047 HAZMAT 8/9/04 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENTDOR 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 10% Late Charge $72.00 <br /> CM3 <br /> n� <br /> TOTAL $72.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AIRGAS-NO.CALIF.-NEVADA 209-993-8653 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3970 N WILCOX RD STOCKTON CA 95215 <br /> 8PeUSE CO-OWNER <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AIRGAS-NO. CALIF.-NEVADA 209-993-8653 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3970 N WILCOX RD STOCKTON CA 95215 <br /> PREPARED BY� I CHECKED B DATE <br /> L C� zap— <br /> /T/Lp/O COL 20 raw: <br />