Laserfiche WebLink
K ; 6 <br /> REIMBURSEMENT REQUEST UNDERGROUND STORAGE TANK CLEANUP FUND <br /> DATE: 7-A3 1, REIMBURSEMENT NO. CLAIM NO. QO`/--2 4' <br /> CLAIMANT: !, S'J�leJff al <br /> 0 PAYEE_• A/✓� <br /> CLAIMANTADDRFM. -�.�5',Z we 5r wELG <br /> CONTAMINATED SITE: �'Tt: - " ,ate 4C.4 <br /> ADDRESS: f Gt.L'3 T ��EIIT ✓``� <br /> W. <br /> State'Use' State:Use <br /> COtST'CATE[iORY LETRR.OF . ' 00= APPROVED <br /> <COJ1�"MITM <br /> INCURRED <br /> FOR PAY11! <br /> � lJNbiJyNT t TODA?8 ' 4 `ODATE <br /> Casts Incurred riot to Re ulations 12/4191 <br /> Assawment <br /> 2; Saovwwarlavesti t�cw <br /> base 3; torreucdve Action lar lenient. . <br /> base 4; Verification Monitoring <br /> ,,. <br /> eext7�le v 10°000 S10 . 000 <br /> TOTAL �f3194/67 <br /> TIFTCA77ON: <br /> have read and agree with the "Conditions of Payment"(Exhibit I),listed on the reverse side <br /> f this document. <br /> The costs daiwed im column(B)Jure been incurred and have been paid".*M be paid within tbrrty(30)efs <br /> f receipt of the funds requested hereby. If such costs have not been paid within 30 days,funds received <br /> t Ia'i�iegtir t roli►l bie•'i at tr&td to the State'water'Reaa cm ControlBoerd <br /> ©slmaat S' tare+ Date. 51. <br /> to Use Qnly:Approval Por Payment , <br /> li G -.x <br /> A:_ -..tL y. {Y;•'}'. vi•:,:< r1 .•�:} k \ F � �'.\`.:12,v±i^?}6 k4i vS \ }. <br /> � !M51etrt to bstb��s� � <br /> tvlew�e By' ; Title <br /> »l<s <br /> . <br /> t <br /> meed Title. w, Dnle=i <br /> Form USTCF-REQ <br /> < a <br />