Laserfiche WebLink
CPG #- TO: FICE OF REVENUE AND RECOVERY <br /> if ACCOUNT TRANSMITTAL 10 C O py <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> IMPERIAL AUTO SPA <br /> C/O NAME GUARANTOR SSN <br /> FRANK REYNOSO <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1211 S TURNPIKE RD STOCKTON CA 95206 (209)405-6915 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 3738 MYKALA DRIVE STOCKTON CA 95212 (209)405-6915 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BMd CBM INT MONTHLY PAY AMT I"PYMT <br /> 14173 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 /> No <br /> 380 042000.0 2011 Hazmat Fee $85.00 <br /> 380 042000.0 State Surcharge Fee $24.00 <br /> 380 042000.0 Electronic Surcharge $25.00 <br /> 1 1 042000.0 Hazmat Penalty Fee $8.50 <br /> 380 042000.0 <br /> 380 042000.0 <br /> 380 042000.0 <br /> TOTAL $142.50 <br /> GUARANTOR <br /> DOB -DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> IMPERIAL AUTO SPA (209)405-6915 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 1211 S TURNPIKE RD STOCKTON CA 95206 <br /> SPOU99 CO—OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> IMPERIAL AUTO SPA (209)405-6915 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 1211 S TURNPIKE RDST CK N L CA 95206 <br /> PREPARED BY CHECKED B ATE 6 1/ f I I COL. zo la�eel <br />