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CPG- #, TO: OFFICE OF REVENUE AND RECOVERY COPY <br /> ACCOUNT <br /> TRANSMITTAL <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> BUTLER'S MOBILE WASHING SERVICE <br /> C/O NAME GUARANTOR SSN <br /> MICHELLE &ALBERT BUTLER <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> BUTLER'S MOBILE WASHING SERVICE P.O. BOX 77891 STOCKTON CA 95267 209-235-5074 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 2474 WIGWAM DRIVE STOCKTON CA 95205 209-235-5074 <br /> USER REFERENCE NO. BILL TAT CYCLE STATUS DATE BM CBMd INT MONTHLY PAY AMT <br /> 13982 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 113/15/1.2 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> ii <br /> SERVICE DATE: DATE OF <br /> TART STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $285.00 8P43009.01 <br /> 30 1 014290010 1 Hazmat Penalty Fee $28.50 p8q4 300p.01 <br /> p8q I q42900f() I State Surcharge Fee $24.00 p8q <br /> 1 1 <br /> �8q o 2 00 0 Electronic Surcharge $25.00 p8q <br /> 1 11 <br /> 80 1 0 2 00 0S 4 00 .0 <br /> so 0 2 00 o s a 00 .o <br /> so 1 0l$2q00.P p8q <br /> 1 1 <br /> TOTAL $362.50 <br /> GUARANTOR <br /> PRIOR STREET CITY RT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BUTLER'S MOBILE WASHING SERVICE 209-235-5074 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 2474 WIGWAM DR#A STOCKTON CA 95205 <br /> ST FIRST MI TITLE SOC SEC NO. I DOB I DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> BUTLER'S MOBILE WASHING SERVICE 209-235-5074 <br /> EMPLOYERSTREET CITY qT 71P c,,onF <br /> 2474 WIGWAM DR#A$T CK C�N CA 95205 <br /> RPP �PnCHECKED BY DATE COL 20 (3/88) <br />