Laserfiche WebLink
CPG # TO: Q ?CE OF REVENUE AND RECOVERY COPY TRANSMITTALACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> R&R MCCULLOUGH MOBILE REPAIR <br /> C/O NAME GUARANTOR SSN <br /> RANDY MCCULLOUGH <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> R&R MCCULLOUGH MOBILE REPAIR 177 S KELLY ST LODI CA 95240 209-334-4305 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 80 ALMO GALT CA 95632 209-334-4305 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE Wd CBMd INd MONTHLY PAY AMT <br /> 12929 HAZMAT 1 <br /> 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE 'RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> r <br /> DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> WR Nf� <br /> 042000.0 2012 Hazmat Fee $285.00 8 4 00 .0 042 000 Hazmat Penalty Fee $28.50 8 Oa oo .01 1 <br /> 42 000 Sm Hw Gen <5 Tons/yr $213.00 8 4 00 .00 2 00 0 1 Permit Fee Penalty $213.00 p8q <br /> 80 1 0142 0010 State Surcharge Fee $24.00 p8q <br /> 80 1 0I42q0010 Electronic Surcharge Fee $25.00 p8q4 00 .0 <br /> 80 1 0I42q00.p 11 p8q400 .0 <br /> TOTAL $788.50 <br /> PRIOR STREET CITy IT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> R&R MCCULLOUGH MOBILE REPAIR 209-334-4305 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 177 KELLY ST LODI CA 95240-3107 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LICNO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> R&R MCCULLOUGH MOBILE REPAIR 209-334-4305 <br /> EMPLOYER STREET cliy <br /> 177 KELLY ST LODI CA 1 952PgrpAgFn <br /> 40-3107 <br /> /4 CHECKED B DATE I COL. zo (3/88) <br />