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VAN DE POLx:2094661910 Mar 21 2013:44 P. 04 DAD
<br /> S1 atc Wator Rcsour=Control Board
<br /> Un ergrdund Storage Tank Cleaup Fund
<br /> r CQNDI'IIQ S QinF'FAYMENT CERTIFICATION
<br /> CLAIM NO.. 18342
<br /> CLAIMANTNAME:VAN DE POL RpRISES INC. CA 95206
<br /> S
<br /> ITE,ADDRESS'.1033 CHARTER WAY W, STOCKTON
<br /> ' form is a requirent
<br /> d suppleUleni to your Rei ursement Requests. Yt tsiust �11 N pT p unlesand anYs oithe
<br /> This
<br /> claimants. All signatures must be ar3ginam NOTE: with
<br /> the Underground Storage Tank Cleanup Fund(Fund).
<br /> "Conditions of Payment cenwadon"formic n,f
<br /> CONDITIONS
<br /> ------------------
<br /> By submisslol� hereof, and a i3 condition of pa meet hereunder, the GI imant warrants and agrees Shat:
<br /> y Tlie.Clalrnant has complied with, and will cornplY with, all applicable state laws, rules and regulations which are a
<br /> condition of payment from the Fund an with all terms, canditipns and commitments in the Claimant's Application,
<br /> and any documents in support thereof.
<br /> ich r•elrnburs:Oment is sou jht re eligible for reimbursement and claimant-Is entitled to reimbursement
<br /> 2. All to5t5 for wh
<br /> therefore. records, and
<br /> 3. The Claimant has estabiisHed and owill de uaMaintain and separate
<br /> accurately reflect and roar fydallucosts claims h other land Claimant's
<br /> documents a5 may be needed tvfor
<br /> entitlement thereto, and Claimant gef orrt the Fund on acc recordsluntaoflcosts at theesite which disbursement sthesubject ofrorf this
<br /> Fund or three Yeas alta Payment.
<br /> The r tention period shall be
<br /> claim, whichever period Is fonger� extended until completion of any audit In progress a
<br /> the time of normal expiration of the retention period, l
<br /> 4. The Claimant.w[ll expeditiously provide any..reports, data, inform ation, or certifications required by the State Water
<br /> Resources Control 66aed (State Water S and).
<br /> 5. The State Water Board or any authorize representative
<br /> f an scosts relevy t toyreimbursement from the Fundtany the ,time during
<br /> paragraph
<br /> the Claimant won period specified ill
<br /> paragraph 3 above, commence an auditY but not limited to, the records specified in
<br /> make avallabVe all necessary books a d records therefore, 1nndfo g,
<br /> Paragraph-3 above, The CValmant agr es to reimburse the Fund far any costs disallowed as a result of such audit
<br /> immediately upon receipt of a copy of s c{i audit.
<br /> so
<br /> m another person oil
<br /> 6. if the 001Mant receives reimbursemtn 11l remit to the Fund an amount equal t th-account of any e sum disbursed from the Fundfor which reimbursement Is on
<br /> received from the Fund, the C that if such cost was advanced to the Claimant under circumstances where
<br /> account of such cd1st,.=_Ad9&' dvance from an
<br /> the Claimant is,obligated t from u c rep Yme no remttta�e t the tE and ifrom s the
<br /> and if the Claimant receives
<br /> no benefit, direct or indire ,
<br /> will be'paid;by the claimant or, i�
<br /> liable, a 7oirit Claimant, Co-Payee, or another person pursuant to
<br /> �. . on eimbursement Request represent actual
<br /> The Claimant certifies that all amountsclaimedamounts that
<br /> have been or applicable,
<br /> CValm
<br /> the terms of a valid"on behalf or agr ement,
<br /> S. Clalrnant•shall provide to the Fund proofaimant,l Co-payee,ts another person pursuant tant o the terms ofhave ea ven alid "oaid n
<br /> the Clairnant or,.if applioable,;a )pin .
<br /> behalf or agreement, will beJ the Fund
<br /> from the Fund, or ny other payment fro or notice that such a payment has been mch the claimant is not iade and in
<br /> 9. Any overpayment
<br /> repaid to the Fund by thq Cla�rrsant+ mediately upon knowledge
<br /> any event, not Vater than 20 days aftr a'written request for repayment by the state water Board or any authorized
<br /> representative thereof. may
<br /> the event of an overbayme.nt by t e Fund for this claim, reimbursements
<br /> solved to the satisfaction of the State Water Board.be
<br /> r all of.Claimant's Fu d Claims
<br /> id. in tis repaid or otherwise)
<br /> held In abeyance until the overpaym
<br /> 1. An repayments due to.the Fund shall bear interest at the highest legal rate from the date due to the Fund to the date
<br /> . Y
<br /> of actual repayment.
<br /> defend and save harmless the S ate, its officers, agents, and employLany
<br /> and all
<br /> 12. The Claimant will indemnify, a ment to the Claimato all
<br /> claims, losses and liability arising out of or connected with any pay
<br /> Reimbursement Requests, including but,not Ilnlited to the asanabie cast of any attorney fess sociated
<br /> court and trial costs, page i of
<br /> continued on Re rcme
<br /> 1ISTGg.C4p".01/07)
<br />
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