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i <br /> fY• <br /> REIMBURSEMENT REQUEST — UNDERGROUND STORAGE TANK CLEANUP FUND <br /> DATE: 7-13-9 3 REIMBURSEMENT NO. 1 CLAIM NO. 4 0 4 6 <br /> CLAIMANT.- ELLIS CAR WASH CO. , INC . _ <br /> CO-PAYEE: NONE <br /> CLAIMANT ADDRESS: 125 NORTH PLEASANT AVENUE <br /> LODI , CALIFORNIA 19F,244-2-6-7 �r7o� f D <br /> CONTAMINATED SITE: ELL I S CAR WASH CO. <br /> ADDRESS: 820 SOUTH CHEROKEE LANE <br /> LODI , CALIFORNIA 95240 <br /> Sta to Use Sta to Use <br /> (A) (B) t� <br /> COST CATEGORY LETTER OF COSTS APPROVED <br /> aG'OMMITMENT INCURRED FOR PA., <br /> AMOUNT TO DATE TO DATE <br /> Costs Incurredprior to Regulations 1212/91 $45169 . 15 <br /> Phase 1; Preliminary Site Assessmcnt 00.E <br /> base 2; Soil/Water Investiga tion G}J.6b 2 , 2 2 9 . 07 <br /> Pbase 3; Corrective Action Implementation <br /> Phase 4; Verification Monitoring <br /> Third Par <br /> Judgmentt � <br /> Deductible S10 000 ($10000) $10 000 <br /> TOTALG0 $37, 398. 22 <br /> CER 77FICA 7TON: <br /> I have read and agree with the "Conditions of Payment"(Exhibit I), listed on the reverse side <br /> of this document. <br /> The casts claimed in column (B) have been incurred and have been paid or will be paid within thirty(30) day <br /> of receipt of the funds requested hereby. If such costs have not been paid within 30 days, funds received <br /> under this request will be returned to the State Water Resources Control Board. <br /> Claimant Signature: J '' Date: <br /> g �/ <br /> State Use Only:Approval for Payment <br /> Less: - = 0/7/ ZAFO-00 <br /> ov For Pa' nt tc Date Previous Payments Amount Due <br /> evie ed By �`� Title: Dater <br /> proved By: Title: Dater <br /> Form USTCF-REQ <br />