Laserfiche WebLink
CPG' # TO: 07L CE OF REVENUE AND RECOVERY <br /> aACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 �f <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> PREMIER INDUSTRIAL FINISHING <br /> C/O NAME GUARANTOR SSN <br /> AURELIO FERNANDEZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> PREMIER INDUSTRIAL FINISHING 954 S MILPITAS BLVD MILPITAS CA 95035 408-649-2500 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1712 VIA FLORES CT. SAN JOSE CA 95132 408-649-2500 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INTJ MONTHLY PAY AMT <br /> AXF- <br /> 12134 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. N MOUNT <br /> WR <br /> 230 042000.0 2012 Hazmat Fee $285.00 8q 1 P43009.01 er <br /> 30 1 014290010 1 Hazmat Penalty Fee $28.50 p8q104300P.0 <br /> �8q I q42900ri) I State Surcharge Fee $24.00 p8q4 00 .0 1 '112 <br /> p8q I 0 2 00 o Electronic Surcharge Fee $25.00 8q 1 P43009-01 <br /> 80 1 014290010 8 4 00 .0 <br /> 80 1 014290010 8 4 00 .0 <br /> 80 1 002qOO.p I p8q4 00 .0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> PRIOR STREET r. qT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> PREMIER INDUSTRIAL FINISHING 408-649-2500 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 17700 SHIDELER PKWY LATHROP CA 95330 <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 /> PREMIER INDUSTRIAL FINISHING 408-649-2500 <br /> EMPLOYER STREET CITY <br /> 17700 SHIDELER PKWY Lf\T P CA 95330 <br /> CHECKED BY JDATE COL. 20 10881 <br />