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- --------- <br /> CPG # TO: OOCE OF REVENUE AND RECOVERY <br /> L <br /> 71rrQTTmP TRANSMITTAL c 0 FD <br /> ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST M1 TITLE LAST AKA FIRST MI TITLE <br /> AMESSA AUTOMOTIVE CENTER <br /> C/O NAME GUARANTOR SSN <br /> JOSE PADILLA VILLA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3943 N WEST LN STOCKTON CA 95204-2435 (209)430-6258 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 8818 BERGAMO CIR STOCKTON CA 95212 (209)430-6258 <br /> USER REFERENCE NO. I BILL TAT ICYCLE ISTATUS DATEI BM d CBM INT� MONTHLY PAY AMT ,PYMT,,T U R <br /> n11PnATP TEWIDAT-F- <br /> 3686 HAZMAT 13/1,5/1,2 <br /> LAST - RECIPIENT - FIRST MI TITLE ---Rr:CIPIENT USER REFERENCE NO/NARRATIVE <br /> 1 F I I I I I I <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> 6E I I I I I I I <br /> C4A DEPT.NO. DESCRIPTION' AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> Nf) <br /> DATE: <br /> STOP <br /> CHARGE rARG E <br /> i042000.0 2012 Hazmat Fee $115.00 p8q 1 P43009.01 1 <br /> 230 <br /> 30 1 014290010 1 Hazmat Penalty Fee $11.50 P89 1 1043009.01 <br /> p8q I q429OOrO I Sm Hw Gen <5 Tons/yr $213.00 �Bq 1 P43009.01 1 <br /> p8q , 0I42Q0 Permit Fee Penalty $213-00 p8q 1 P43009.01 <br /> Lj <br /> �801 I 0 2q0010 I State Surcharge Fee $24.00 P89 I P44009.1), <br /> ?801 1 * qooio I Electronic Surcharge Fee $25.00 8q 11 P43009.01I <br /> 01 0I42q00.p p8q 11 P44009.01 <br /> TOTAL $601.50 <br /> nr)R nPIT ITO I ,-In -;;ARA-NMGR- <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AMESSA AUTOMOTIVE CENTER (209)430-6258 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3943 IN WEST LN STOCKTON CA 95204-2435 <br /> AST FIRST M1 TITLE1 SOC SEC-NO. I DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> AMESSA AUTOMOTIVE CENTER (209)430-6258 <br /> EMPLOYER STREET rITY RT 71P CQQF <br /> 943 IN C��, <br /> WEST LN S T 0 N// CA 95204-2435 <br /> ' TO <br /> Rp:PA14�ngy/, CHECKED BY JDAT E COL. 20(W8 <br />