Laserfiche WebLink
TO: OFFICE OF REVENUE & RECOVERY <br />ClIG: ACCOUNT TRANSMITTAL <br />ACCOUNT NO DEPT NO REFERRAL DATE <br />0420000 <br />LAST - -GUARANTOR- FIRST <br />MI <br />LAST AKA FIRST MI <br />Beethan <br />Dennis <br />C/O NAME <br />SSN/ FED # <br />DR. LIC. NO. <br />DB Western <br />MAILING ADDRESS <br />CITY <br />STI <br />ZIP <br />AREA PHONE # <br />12511 Strang Rd <br />La Port <br />TX <br />77571 <br />(541) 217-1595 <br />FACILITY ADDRESS <br />CITY <br />ST <br />ZIP <br />2650 W Washington St <br />Stockton <br />CA <br />95203 <br />(209) 937-9530 <br />USER REFERENCE NO <br />INVOICE NO. 276460 <br />SERVICE DATE: <br />COMMENTS: <br />Add'I Phone#:281-867-1330 <br />START <br />STOP <br />2/2/2016 <br />3/15/2016 <br />CHARGE <br />No <br />DEPT NO <br />DESCRIPTION <br />AMOUNT <br />CHARGE <br />No <br />DEPT NO <br />DESCRIPTION <br />AMOUNT <br />INVOICE # 276460 <br />230 <br />042000 0 <br />HMBP-Reg-Primary Location <br />315.00 <br />380 <br />042000 0 <br />State Surcharge Fee FY 15/16 <br />35.00 <br />380 <br />042000 0 <br />HazMat Program Penalty Fee <br />31.50 <br />b <br />TOTAL <br />381.50 <br />EMPLOYER NAME/SOURCE OF INCOME: EMPLOYER PHONE # <br />EMPLOYER STREET CITY <br />IST <br />ZIP <br />PREPARED BY: <br />DATE: S a 6 <br />i <br />REVIEWED BY: -1i;j pL ., 4 �% <br />DATE: 'I� . <br />