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CPG #� TO: aFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRALc on <br /> 026000.0 ..-.- <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MANTECA EQUIPMENT RENTAL <br /> C/O NAME GUARANTOR SSN <br /> MANTECA EQUIP RENTAL <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 616 S MAIN ST MANTECA CA 95337 209-239-3507 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 616 S. MAIN ST. MANTECA CA 95337 209-239-3507 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I PYMT PROB <br /> 968 HAZMAT 4/15/11 <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 HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> Nn <br /> 230 042000.0 2011 Hazmat Fee $345.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $34.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 002000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $854.50 <br /> GUARANTOR <br /> DOB I DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MANTECA EQUIPMENT RENTAL 209-239-3507 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 616 S MAIN ST MANTECA CA 95337 <br /> CO—OWNER <br /> ST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO I AUTO LIC NO <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MANTECA EQUIPMENT RENTAL 209-239-3507 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 616 S MAIN ST MANT ACA 95337 <br /> REPARED BY CHECKED BY DATE ��y 7�7/ c0L. N (cree)) <br />