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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> CO <br /> ACCOUNT NO. DEPT. NO. REFERRAL �s ''urn/) <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> R&R MCCULLOUGH MOBILE REPAIR <br /> C/O NAME GUARANTOR SSN <br /> RANDY MCCULLOUGH <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> R&R MCCULLOUGH MOBILE REPAIR 177 S KELLY ST LODI CA 95240 209-334-4305 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 80 ALMO GALT CA 95532 209-334-4305 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMI CBMI INT MONTHLY PAY AMT PYMT PR <br /> ni IP DATE TERM nATF <br /> 12929 HAZMAT I 1 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1.4/1 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> hin230 042000.0 2011 Hazmat Fee $285.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $28.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen <5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 HA <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 380 042000.0 <br /> 380042000.0 380 042000.0 <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 PHONENO <br /> R&R MCCULLOUGH MOBILE REPAIR 209-334-4305 <br /> EMPLOYER STREET CITY ST I ZIP CODE <br /> 177 KELLY ST LODI CA 95240-3107 <br /> CO-OWNER <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 /> R&R MCCULLOUGH MOBILE REPAIR 209-334-4305 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 177 KELLY ST LODI CA 95240-3107 <br /> REPARED B CHECKED BY DATE 7� 7 .// ppL. 20(3IBB) <br />