Laserfiche WebLink
CPG # T0: FFICE OF REVENUE AND RECOVERY • COPY <br /> ACCOUNT TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> nATr <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MITITLE LAST - AKA - FIRST MI TITLE <br /> PERFORMANCE MACHINE <br /> C/O NAME GUARANTOR SSN <br /> WALT OTT <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 11667 PALM LN UNIT FMANTECA CA 95336 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-484-7987 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> PYMT PROS <br /> 13222 HAZMAT 3/20/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO DESCRIPTION AMOUNT <br /> 380 042000.0 2011 Hazmat Fee $270.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 380 042000.0 Hazmat Penalty Fee $27.00 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $346.00 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET RPHONE <br /> ST ZIP CODE <br /> I <br /> EMPLOYER NAME EEMPLOYERPERFORMANCE MACHINE <br /> EMPLOYER STREET ST I ZIP CODE <br /> 11667 PALM LN UNIT F MANTECA CA 95336 <br /> SPOt3SE CO-OWNER <br /> MEMPLOYERSTREET <br /> FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER PHONE NO <br /> CHINE <br /> CITY ST ZIPCODE <br /> IT F.MANTEC/a, CA 95336 <br /> REPARED BY CHECKED BY coy. 20 laieel <br />