Laserfiche WebLink
CPG # TO: ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL • /c O py <br /> ACCOUNT N0. DEPT. NO. REFERRAL /\/\V_ <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ORTEGA ROAD SERVICE <br /> 0/0 NAME GUARANTOR SSN <br /> JOSE LUIS ORTEGA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> ORTEGA ROAD SERVICE 160 W 4TH ST STOCKTON CA 95206 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. BILL TAT CYCLE I STATUS IDATE1 BMd CBMnil <br /> INT MONTHLY PAY AMT PYMT PROB <br /> 14217 HAZMAT 11/15/09 <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 /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 1 Chem @ $15.00 $15.00 to <br /> 10% Late Charge $8.50 low <br /> i. <br /> i <br /> TOTAL $93.50 <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 /> ORTEGA ROAD SERVICE <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1759 MARIPOSA RD STE B STOCKTON CA 95206 <br /> SPOUS& CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. I DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ORTEGA ROAD SERVICE <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 1759 MARIPOSA RD STE T C TON CA 95206 <br /> REPARED BY CHECKED BY _ DATE J 1 /,�, COL. 20 (3188) <br />