Laserfiche WebLink
CPG^# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ' OFT <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> SARROS' AG WELDING AND TRAILER <br /> ^C/O NAME GUARANTOR SSN <br /> JJGS CORP <br /> MAILING STREET CITY ST ZIPCODE AREA PHONE NO. <br /> BARROS'AG WELDING AND TRAILER REPAIR 1623 THIRD ST ESCALON CA 95320 209-838-6425 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1623 THIRD STREET ESCALON CA 95320 209-838-6425 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMI CBMINT MONTHLY PAY AMT <br /> 11518 HAZMAT 3/20/10 <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 /> 230 026000.0 2010 Hazmat Fee $270.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge $25.00 <br /> Hazmat Penalty Fee $27.00 <br /> TOTAL $346.00 <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 /> BARROS' AG WELDING AND TRAILER REPAIR 209-838-6425 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 26414 LONE TREE RD ESCALON CA 95320 <br /> SPOU&r 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 /> BARROS'AG WELDING AND TRAILER REPAIR 209-838-6425 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 26414 LONE TREE RDE CSA CA 95320 <br /> PREPARED BY CHECKED B ATE ,j���3//,� COL. 20 (3/88) <br />