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State of California Department of Resources Recycling and Recovery (CalRecycle) <br /> CalRecycle 172 (Rev.03/12) <br /> INVOICE REQUEST(ACCOUNTS RECEIVABLE) <br /> ACCOUNTING OFFICE <br /> SECTION A-CONTACT INFORMATION <br /> REQUESTOR: INVOICE PROCESSOR: <br /> DIVISION: CalRecycle/Accounting MS #: 10A NAME: LISA CHAN <br /> NAME: KEITH CAMBRIDGE ACCOUNTS RECEIVABLE DESK <br /> DATE: 01 / 05 / 2015 PHONE#: 916-341-6422 FISCAL SERVICES BRANCH-ACCOUNTING OFFICE <br /> SECTION B-NEEDED INFORMATION <br /> N ote: <br /> ■ Please allow 5-7 working days to process the Invoice Request. <br /> • All invoices must be mailed out with a cover letter attached. <br /> Cover Letter: <br /> ❑ Cover Letter Attached (to be sent out with invoice, use the following font for cover letters: Book Antiqua, Size 10) <br /> ® Cover Letter to be completed by the Invoice Processor. Please provide ample information to process the cover <br /> letter. (Complete section E) <br /> Backup: <br /> ❑ Backup necessary for Accounting's Files (i.e., adjustments, audit findings, etc.) <br /> ❑ Backup (i.e.spreadsheets, contracts, purchase orders, memos,agreements,etc.) <br /> Payment Plan: <br /> ® Yes (Please provide payment plan information as it will appear in the body of the Invoice): <br /> ❑ No <br /> SECTION C-INVOICE BODY <br /> EXPLANATION INFORMATION THAT WILL APPEAR IN THE BODY OF THE INVOICE): <br /> In January 2015, MLTR Company entered into an agreement with CalRecycle that their company will pay the sum total of <br /> $4,000 (2.4 monthly payments of$166, final payment of$182) for violations of the Public Resources Code§42951(b), hauling <br /> waste tires to on unauthorized location,specifically four violations that occurred between August 13,2014 to October 6, 2014. <br /> This Stipulation was signed on January 5, 2015. Please send invoices to collect the penalty amount. <br /> SECTION D-REQUIRED INFORMATION <br /> COMPANY/AGENCY (PAYER)TO BE BILLED: MLTR Company <br /> CONTACT PERSON (PAYER): Virginia Lavagnino <br /> ADDRESS OF PAYER: 2513 Stern PI <br /> Stockton, CA 95206-5909 <br /> PHONE NUMBER: 209-986-1614 <br /> INVOICE AMOUNT: $4,000.00 FISCAL YEAR: 2014/15 FUND: Tire <br /> OTHER INFORMATION: (ADDITIONAL INFORMATION REQUIRED BY THE ACCOUNTING OFFICE) <br /> Full payment amount is$4,000, operator agreed to pay 24 monthly payments of$166 (final payment to be$182). No payment <br /> has been collected to date. <br /> SECTION E-INFORMATION NECESSARY FOR COVER LETTER <br /> 1771973 <br /> MLTR Company <br /> 2513 Stern PI <br /> Stcckton, CA 95206-5909 <br />