Laserfiche WebLink
CPG•# TO: OFFICE OF REVENUE AND RECOVERY <br /> jft ACCOUNT TRANSMITTAL CopyACCOUNTNO. DEPT. NO. REFERRAL026000.0 <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 11 . 1 11 <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> TED'S WELDING& REPAIR P.O. BOX 726 VICTOR CA 95253 209-368-9864 OR <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> P.O. BOX 611 VICTOR CA 95253 209-603-8979 <br /> USER REFERENCE NO. BILL TAT CYCLE ISTATUS DATEI BM CBM INTI MONTHLY PAY AMT I <br /> PYMT PROS <br /> TF <br /> 2876 HAZMAT 3/20/10 <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 026000.0 Sm Hw Gen<5tons/yr $213.00 <br /> 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 LM <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $28.50 -°.i,•. <br /> Permit Fee Penalty $213.00 <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 /> SPOUfT} 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 /> EMPLOYERS FEET CITY ST ZIP CODE <br /> 8932 E HWY 12VICTQ CA 95253 <br /> REPARED BY CHECKED BY JDAIE �'-'7/� Coy. 20 (3rea)) <br />