Laserfiche WebLink
CPGO# TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ' py <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> GOLDEN GATE ORN IRON WORKS <br /> C/O NAME GUARANTOR SSN <br /> JESUS T VALENZUELA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2489 E MINER AVE STOCKTON CA 95205 209-941-4090 <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO. <br /> 209-941-4090 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT PYMT PR B <br /> 6139 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 Sm Hw Gen <5 Tons/yr $213.00 <br /> 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $788.50 <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 /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2489 E MINER AVE STOCKTON CA 95205 <br /> SPOUSE- 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 /> GOLDEN GATE ORN IRON WORKS 209-941-4090 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 2489 E MINER AVE STQ. KT. CA 95205 <br /> PREPARED BY CHECKED BY DATE -/p COL. 20 lareel <br />