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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL <br /> REFERRAL "'� <br /> ACCOUNT NO. DEPT � D <br /> 026000.01 Li <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FI 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 95632 209-334-4305 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM INT MONTHLY PAY AMT Pni IFYMTnATF TpphfinATP <br /> OB <br /> 12929 HAZMAT 1.3/20/1.0 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> DQU <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRI ON AMOUNT <br /> Nn <br /> 230 026000.0 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $788.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <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 /> SPOU49 CO—OWNER <br /> AST 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 LO ICA 1 95240-3107 <br /> REPARED BY CHECKED BY DATE <br />