Laserfiche WebLink
CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL zopy <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ELITE CLEANERS <br /> C/O NAME GUARANTOR SSN <br /> DIMPLE/HINA PATEL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3201 W BENJAMIN HOLT DR #119STOCKTON CA 95219 209-957-9361 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 6270 STONERIDGE MALL ROAD#C103 PLEASANTON CA 94588 209-957-9361 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT YM <br /> 9906 HAZMAT I 1 11 11 11 1 1 1 1 1 1 1 1 1 1.3/20/1.0 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE 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 /> mn <br /> 230 026000.0 Sm Hw Gen <5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $255.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $25.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $755.50 <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 /> ELITE CLEANERS 209-957-9361 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3201 W BENJAMIN HOLT DR#119 STOCKTON CA 95219 <br /> SPOUS€ 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 /> ELITE CLEANERS 209-957-9361 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3201 W BENJAMIN H LT DR# STOCKTON CA 95219 <br /> REPARED I CHECKED BY IDATE ,7S_��j COL. 20 (3W) <br />