Laserfiche WebLink
CPG #t TO: ICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL C (oFly '026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST AKA - FIRST MI TITLE <br /> DAN'S AUTO REPAIR <br /> I = I I—L--A <br /> CIO NAME GUARANTOR SSN <br /> DAN HOUSTON <br /> ld I <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1533 S STOCKTON ST LODI CA 95240 209-334-2969 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-334-2969 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT MONTHLY PAY AMT I rw <br /> MT R B <br /> 9131 HAZMAT 3115/09 <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 C HARGE DEPT,NO, DESCRIPTION AMOUNT <br /> 230 026000.0 2009 Hmmp Annual Fee $70.00 <br /> 2 Chems @ $15.00 Each $30.00 <br /> JLt <br /> 10% Late Charge $10.00 <br /> State Surcharge Fee $24.00 <br /> I I ftl <br /> TOTAL $134.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST Z!P CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DAN'S AUTO REPAIR 209-334-2969 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1533 S STOCKTON ST LODI CA 95240 <br /> SpASS& CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I 1 <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DAN'S AUTO REPAIR 209-334-2969 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1533 S STOCKTON ST LODI CA 9 40 . <br /> REPARED BY gai CHECKED BY jDATE �� COL. 20 (3188) <br />