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CPG-"# TO: OWE OF REVENUE AND RECOVERY <br /> ACCOUNT.' TRANSMITTAL <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> COPY026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> DANS TIRE AND AUTO REPAIR LLC <br /> C/O NAME GUARANTOR SSN <br /> CLIFF HALL <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 /> 1533 S STOCKTON ST LODI CA 95240 209-334-2969 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT <br /> 14236 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> Ba_ <br /> O <br /> SERVIC DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPTNR - .NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. N AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $115.008P43009.0 <br /> I IRA <br /> 30 014290010 Hemet Penalty Fee $11.50 pq L043019.0 <br /> 38q I q42900,0 State Surcharge Fee $24.00 P89 P43009.0, <br /> p8q 1 014290010 Electronic Surcharge Fee $25.00 p8q <br /> 80 1 014290010 p1q 1 P43009..011 <br /> 80 1, 042 0010 1 18 4 00 .0 <br /> 80 1, 0 2900.p P89 1 P43009.01 <br /> GUARANTOR TOTAL $175.50 <br /> PRIOR STREET CITY RT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> DANS TIRE AND AUTO REPAIR LLC 209-334-2969 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1533 S STOCKTON ST LODI CA 95240 <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 /> DANS TIRE AND AUTO REPAIR LLC 209-334-2969 <br /> EMPLOYER STREET CITY <br /> 1533 S STOCKTON STLO I CA 95240 <br /> CHECKED BY DATEcoy. 20 131eel <br />