Laserfiche WebLink
CPG # TO: O*E OF REVENUE AND RECOVERY <br /> TRANSMITTAL Copy <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> WEST LANE RADIATOR <br /> C/O NAME GUARANTOR SSN <br /> FORTUNE& FORTUNE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3941 N WEST LN STOCKTON CA 95204 209-948-1638 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8312 BURGUNDY DR. STOCKTON CA 95210 209-948-1638 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd IN MONTHLY PAY AMT <br /> 5601 HAZMAT 1.3/115/1.2 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPI-- 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 2012 Hazmat Fee $330.00 P89 <br /> 30 042 00 0 I Hazmat Penalty Fee $33.00 P89 <br /> 1 1 <br /> p8q I q42900rO Sm Hw Gen <5 Tons/yr $213.00 p8q <br /> p8q 0 2 0010 1 Permit Fee Penalty $213.00 p8q <br /> 8 2 00 0 I State Surcharge Fee 1 $24.00 p8q <br /> 1 1 <br /> 80 1 014290010 Electronic Surcharge Fee $25.00 p8q 043009.0, <br /> 80 0 2 00. 8 4 oo .0 <br /> TOTAL $838.00 <br /> PRIOR STREET rITv R ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WEST LANE RADIATOR 209-948-1636 <br /> EMPLOYERSTREET CITY ST ZIP CODE <br /> 3941N WEST LN STOCKTON CA 95204 <br /> ST FIRST MI TITLE SOC SEC NO. I DOB I DR LIC NO AUTO LIC NO <br /> I 1 I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> WEST LANE RADIATOR 209-948-1638 <br /> EMPLOYER STREET CITY <br /> 3941 N WEST LN STOCKTON CA 95204 <br /> CHECKED BY IDATE COL. 20 (3188) <br />