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CPGi# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANS2dITTAL �n�vJ1 py ACCOUNT NO. DEPT.NOREFERRAL ((� <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> FERMIN ALUSTIZA <br /> C/O NAME GUARANTOR SSN <br /> FERMIN ALUSTIZA <br /> MAILING STREET CITY ST ZIP QODE AREA PHONE NO. <br /> FERMIN ALUSTIZA 8250 SEGARINI CT STOCKTON CA 95209 209-946-0450 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8250 SEGARINI CT STOCKTON CA 95209 209-472-9385 <br /> USER REFERENCE NO. BILL TAT ICYCLE ISTATUS DATEI BMd CBMd INd MONTHLY PAY AMT <br /> 13611 HAZMAT 3/15/12 <br /> ftAKuzs <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> i i i i i== I I j - - t i i i i I I , I , - L <br /> SER CE DATE DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $270.00 p8q <br /> 1 1 <br /> 30 0142 00 0 Hazmat Penalty Fee $27.00 p8q104300P.0 <br /> p8q 1 q429OOrO State Surcharge Fee $24.00 p8q <br /> 1 1 <br /> p8q 1 0142900,0 Electronic Surcharge Fee $25.00 8q i P43009.01 <br /> 8 <br /> 92 000 8P43009.01 <br /> 80 0 2 00 0 1 p8q4 00 .0 <br /> 8 0 2400.p 1 289400 .0 <br /> TOTAL $346.00 <br /> GUARANTOR <br /> PRIOR STREET rITY ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> FERMIN ALUSTIZA 209-946-0450 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 820 CHANNEL ST STOCKTON CA 95202 <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 /> FERMIN ALUSTIZA 209-946-0450 <br /> EMPLOYER STREET rITY IP <br /> 820 CHANNEL ST,STYT?;L CA 95202 <br /> �RFPApr:n Ry <br /> CHECKED BY COL. 20 Iareel <br />