Laserfiche WebLink
GPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL ACCOUNT NO. DEPT.NO. REFERRAL COPY <br /> 026000.0 <br /> LAST - GUARANTOR FIRST MI TITLE LAST AKA FIRST MI TITLE <br /> PCI-PAINTING <br /> C10 NAME GUARANTOR SSN <br /> PCI { <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 620 SAN JUAN AVE STOCKTON CA 95203 209-460-0498 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO, <br /> 620 SAN JUAN AVE STOCKTON CA 95203 209-460-0498 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT PYM7 PROB <br /> 13313 HAZMAT 3/20111 <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 hi DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. ESCRIPTION AMOUNT <br /> 360 042000.0 2011 Hazmat Fee $255.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 1 UP mw <br /> 11 042000.0 Hazmat Penalty Fee $25.50 <br /> n <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> OX <br /> TOTAL $329.50 <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 I di I I <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET - CITY ST ZIP CODE <br /> 620 SAN JUAN AVE STOCKTON �E� CA 95203 <br /> &�9CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> 11111 -L--L--L- 1111 I III <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PCI-PAINTING 209-460-0498 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 620 SAN JUAN AVE STOCKTO CA 95203 <br /> PREPARED BYLt2s�g�� 61rl1 CHECKED BY 0211,4 ,f5TE / COG. 20(3M) <br />