Laserfiche WebLink
CPG'# TO: OFFICE OF REVENUE AND RECOVERY COPY <br /> ACCOUNT TRANSMITTAL • <br /> ACCOUNTNO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> TED'S WELDING & REPAIR <br /> C/O NAME GUARANTOR SSN <br /> BILL(GEORGE) BRAUN <br /> MAILING STREET CITY ST ZIPCODE AREA PHONENO. <br /> TED'S WELDING & REPAIR P.O. BOX 726 VICTOR CA 95253 209-368-9864 OR <br /> RESIDENCE STREET CITY ST ZIPCODE AREA PHONE NO, <br /> P.O. BOX 611 VICTOR CA 95253 209-603-8979 <br /> USER REFERENCE NO. I BILL TAT CYCLE STATUS DATE SM CBMC INT MONTHLY PAY AMT MT PRO <br /> 2876 HAZMAT 1.4/15/11 <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 042000.0 2011 Hazmat Fee $285.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $28.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 3801 1, 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 1. 042000.0 <br /> 380 042000.0 380 042000.0 <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 /> TED'S WELDING & REPAIR 209-368-9864 OR 209 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8932 E HWY 12 VICTOR CA 95253 <br /> 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 /> TED'S WELDING & REPAIR 209-368-9864 OR 209 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 8932E HWY 12 VI TOR CA 95253 <br /> PREPARED BY _ CHECKED BY DATE . y —�/ COL. 20 <br />