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CPG e# T0: OFFICE OF REVENUE AND RECOVERY <br /> OPY <br /> ACCOUNT TRANSMITTAL <br /> a ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> V&J ORNAMENTAL IRONWORKS <br /> C/O NAME GUARANTOR SSN <br /> VICTOR RIVARN/JAIME SALAS <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1201 N FILBERT ST STOCKTON CA 95205 209-465-3407 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-465-3407 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBMd INT] MONTHLY PAY AMT <br /> 13231 HAZMAT 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SER E: DATE OF <br /> ART STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $285.00 p8q p4 oo .0 <br /> 30 1 0142 00 o I Hazmat Penalty Fee $28.50 p8q 014 00 .0 <br /> pq I q42900,0 State Surcharge Fee $24.00 p8q <br /> p8q I 0 2 00 0 I Electronic Surcharge Fee $25.00 p8q <br /> 80 1 014290010 8P43009.01 <br /> so 1 02000 I R8q1400 .0 <br /> eo 1 o z 0o,p I psq P4300P.0 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> nOR DR I Ir NO <br /> PRIOR STREET CITY qT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> V&J ORNAMENTAL IRON WORKS 209-465-3407 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1201 N FILBERT ST STOCKTON CA 95205 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> V&J ORNAMENTAL IRON WORKS 209-465-3407 <br /> EMPLOYER STREET CITY ST 71P r.QQF: <br /> 1201 N FILBERT ST STO KT CA 95205 <br /> CHECKED BY DATE COL. 20 lareal <br />