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REIMBURSEMENT REQUEST - UNDERGROUND STORAGE TANK CLEANUP FUND <br /> CLAIM NO: 008531 REGION: 5 REIMBURSEMENT NO: <br /> CLAIMANT. HERMAN & HELEN'S MARINA <br /> CO-PAYEE: NONE <br /> JOINT CLAIMANT: NONE <br /> DAVE SMITH <br /> CLAIMANT ADDRESS: VENICE ISLAND FERRY <br /> STOCKTON, CA 95219 <br /> CONTAMINATED SITE. HERMAN & HELEN'S MARINA <br /> ADDRESS: VENICE ISLAND FERRY <br /> STOCKTON, CA 95219 <br /> LETTER OF COMMITMENT $10,000 AMENDMENT NO: 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 /> 2. THIRD PARTY JUDGEMENT $ $ <br /> 3. ADJUSTMENT $ ( ) $ <br /> 4. DEDUCTIBLE (Subtract) $ (5,000) $ (5,000) <br /> TOTAL (lines 1, 2, 3 & 4) $ $ <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 reverse side <br /> 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 funds <br /> requested hereby. If such costs have not been paid within 30 days,funds received under this request will be returned to the <br /> 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 />