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NOW <br /> REIMBURSEMENT REQUEST - UNDERGROUND STORAGE TANK CLEANUP FUND <br /> CLAIM NO. 009708 REGION: 5 REIMBURSEMENT NO. <br /> CLAIMANT.• William W. Miles <br /> CO-PAYEE: None <br /> JOINT CLAIMANT.• Mrs. Patricia L. Nolet <br /> Mr. William W Miles <br /> CLAIMANT ADDRESS: P.O. BOX 1288 <br /> Los Altos, CA 94023 <br /> CONTAMINATED SITE: Independent Trucking Co. <br /> ADDRESS: 1145 W. Charter Way <br /> Stockton, CA 95206 <br /> LETTER OF COMMITMENT AMOUNT.• $80,000 AMENDMENT: 0 <br /> PROJECT COSTS INCURRED TO DATE APPROVED FOR <br /> (This Section to be completed by claimant) PAYMENT (TO DATE) <br /> (State,Use Only) <br /> 1. CORRECTIVE ACTION COSTS $ $ <br /> (Costs entered here must be cumulative, <br /> total-to-date, NOT INCREMENTAL. <br /> See Reimbursement Request Instructions) <br /> 2. THIRD PARTY JUDGMENT $ $ <br /> 3. DEDUCTIBLE (Subtract) $ (10 000) $ (10,000) <br /> TOTAL (Lines 1, 2 & 3) $ IF $ <br /> CERTIFICATION. <br /> I have read and agree with the "Conditions of Payments" (Exhibit I), listed on the reverse side of this document. <br /> NOTE: This request CANNOT BE PROCESSED unless the "Conditions of Payments"are included on the <br /> reverse side when submitted. <br /> The costs claimed have been incurred and have been paid or will be paid within thirty (30) days of receipt of the <br /> funds requested hereby. If such costs have not been paid within 30 days,funds received under this request will <br /> be returned to the State Water Resources Control Board. <br /> CLAIMANT SIGNATURE: DATE: <br /> STATE USE ONLY: APPROVAL FOR PAYMENTS <br /> $ LESS: $ _ $ <br /> Approved for Payment to Date Previous Payments Amount Due <br /> Reviewed By: Title: Date: <br /> Approved By: Title: Date <br /> Form USTCF-REQ (Rev. 6193) <br />