Laserfiche WebLink
Cpt•# TO: O E OF REVENUE AND RECOVERY <br /> TRANSMITTAL <br /> ACCOUNT NO. PT.NO. REFERRAL <br /> DECOPY <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ABC RADIATOR <br /> C/O NAME GUARANTOR SSN <br /> EDWARD FORTUNE <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 601 S WILSON WAY STOCKTON CA 95205 209-463-7401 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 209-463-7401 <br /> PYMT PRO <br /> USER REFERENCE NO. BILL hTAT CYCLE STATUS DATE BM CBM IN MONTHLY PAY AMT <br /> 942HAZMAT 1. 3/115/1.2 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT.NO. DESCRIPTION AMOUNT CHARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $330.008 1 P43009.01 <br /> 30 1 014290110 1 Hazmat Penalty Fee $33.00 8 1 04 00 .0 <br /> 8q42900,0 Sm Hw Gen <5 Tons/yr $213.00 8 1 P43009.01 <br /> �18q 1 014290010 Permit Fee Penalty $213.00 8 1 P43009.01 <br /> 80 0 2 goolo State Surcharge Fee $24.00 8P43009.01 <br /> 800 2 90010 Electronic Surcharge Fee $25.00 8P43009.0 <br /> 80 11 002qOO.p I P8q4 00 .0 <br /> TOTAL $838.00 <br /> PRIOR STREET rITY AT ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ABC RADIATOR 209-463-7401 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 601 S WILSON WAY STOCKTON CA 952 15 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ABC RADIATOR - 209-463-7401 <br /> EMPLOYER STREET <br /> 601 S WILSON WAY STO KT� CA 1 95205 <br /> CHECKED BY IDATE ,I COL. 20 (arae) <br />