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'JJ State of California Ur ' ',round Storage Tank Cleanup Fur= State water Resources Control Board <br /> Environmental Protection Agency UTTER OF COMMITMENT (Revised 4'97) <br /> A <br /> DATA SHEET <br /> Claimant: Claim No.: <br /> VALLEY WATER TREATMENT 018449 <br /> Claim Contact: Telephone No.: <br /> TED SWANSON 91b '721 _'zl6 g <br /> The information requested on this form must be completed within ten-(10) working days of receipt of this form <br /> or the issuance of your Letter of Commitment may be delayed. It is important that the information provided be <br /> as accurate and complete as possible. Once a Letter of Commitment is issued and funding is committed to <br /> reimburse you for your eligible costs, you will be required to submit your first reimbursement request within 90 <br /> calendar days from the date of the letter transmitting the Letter of Commitment. Failure to submit your <br /> reimbursement request within 90 days will.result in steps taken to withdraw your Letter of Commitment. <br />` L SITE STATUS/COSTS <br /> 1. INCURRED (PAST) COSTS: $_� <br /> DESCRIBE ACTIVITIES(WORK CONDUCTED): <br /> 2. PROPOSED (FUTURE) COSTS: S_. s( (WITHIN THE NEXT 6 MONTHS) <br /> DESCRIBE ACTIVITIES(PROPOSED WORK): p '�,` <br /> E <br /> NOTE: The initial.amount of your Letter of-Commitment will be based substantially upon the information you supply <br /> above. You may provide additional information regarding the corrective action activities on the back of this form. <br /> Failure to complete this information will delay the award of your Letter of Commitment. <br /> II. INCURRED COST SUMMARY <br /> List a complete summary of eligible corrective action costs incurred to date. Do not include tank removal costs, attorney <br /> fces. At thifi <br /> S time,you are not required to submit the actual invoices or list individual invoices. List the'firms and the <br /> total costs for each firm. An example summary is provided below: <br /> 4 FIRM TOTAL AMOUNT <br /> (SAMPLE) ABC CONSULTANTS _ $34.575.00 <br /> i NOTE: Only list those firms which have actually invoiced you. Do not list proposals. Do not list subcontractors whose <br /> bills are already included in the prime consultant/contractor invoice. <br /> Completed By: _M11 Y VA/A N 5 Date: <br /> Claimant Signature: 22 <br /> eDate: L <br /> RETURN COMPLETED FORM WITH ORIGINAL SIGNATURE TO: Barbara Rempel, ECEI E <br /> State Water Resources Control Board, P.O. Box 944212, Sacramento, CA 94244-21.20 DE <br /> C 0 205s <br /> l <br /> UST CLEANUP FUND <br />