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TOFFICE OF REVENUE & RECOVERY • <br /> CPG: ACCOUNT TRANSMITTAL <br /> ACCOUNTNO DEPT NO REFERRAL DATE <br /> 0420000 <br /> LAST- -GUARANTOR. FIRST mll LAST AICA FIRST MI <br /> Mendoza Juan <br /> CIO NAME SSN/FED# DR.LIC.NO. <br /> Mendoza's Auto Body & Paint <br /> MAILING ADDRESS CITY ST ZIP AREA PHONE# <br /> 2538 N West Ln#19-20 Stockton CA 95205 <br /> FACILITY ADDRESS CITY ST ZIP <br /> 2538 N West Ln#19-20 Stockton CA 95205 (209) 941-2849 <br /> USER REFERENCE NO <br /> Invoice#0263108 <br /> COMMENTS: <br /> SERVICE DATE: <br /> START STOP <br /> 1/29/2015 4/15/2015 <br /> CHARGE <br /> E ce <br /> DEPT NO DESCRIPTION AMOUNT NO <br /> CE DEPT NO DESCRIPTION AMOUNT <br /> Invoice#0263108 <br /> 230 0420000 HMBP-Common Materials $ 255.00 <br /> 380 0420000 2015 Sm HW Generator Permit 213.00 <br /> 380 0420000 State Surcharge Fee FY 14/15 35.00 <br /> 230 1 0420000 Haz Mat Penalty Fee 25.50 <br /> 380 0420000 Permit Fee Penalty 213.00 <br /> TOTAL 741.50 <br /> EMPLOYER NAME/SOURCE OF INCOME: JEMPLOYER PHONE# <br /> EMPLOYER STREET CITY ST ZIP <br /> PREPARED BY: DATE: <br /> REVIEWED BY: DATE: <br />