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REIMBURSEMENT REQUEST- UNDERGROUND STORAGE TANK CLEANUP FUND CLAIM NO: 012750 REGION. 5 REIMBURSEMENT NO: CLAIMANT. Inland Paint Company CO-PAYEE: None JOINT CLAIMANT.. None CLAIMANT ADDRESS: 117 West Harding Way Stockton, CA 95204 CONTAMINATED SITE: Inland Paint Company ADDRESS: 117 West Harding Way i Stockton, CA 95204 LETTER OF COMMITMENT. AMENDMENT NO: PROJECT COSTS INCURRED TO DATE APPROVED FDR (This Section to he completed by claimant) (State66 1. CORRECTIVE AC77ON COSTS (Costs entered here inust he cumulative, .......... ... ...... .......... Total-to-date,NOT INCREMENTAL) $ Z THIRD PARTY JUDGEMENT S ......... ........ . .... ... .3. ADJUSTMENT $ 4. DEDUCTIBLE(Subtract) $ 5,000 ........... TOTAL 4,-1 to, ............... ...... CERTIFICATION.• I have read and agree with the "Conditions of Payments"(Exhibit 1), listed on the reverse side of this document. NOTE. This request CANNOT BE PROCESSED unless the "Conditions of Payments"are included on the reverse side when submitted The costs claimed have been incurred and have been paid or will be paid within thirty (30) days of receipt of the funds requested hereby. If such costs have not been paid within 30 days,funds received under this request will he returned to the State Water Resources Control Board CLAIMANT SIGNATURE: DATE. . . ........... .. .STATE USE(1NLY APPROVAL FOR.PAYMEITS. . . ... .................. ............ J .......... ............... .. . ...... ............. .... ........ ........... .... . ...... . . . . .. . . . . .. Ad Pavment:1 D; P. .............. fi— : ...ayniertits Amount Due ......... . ............... ... ....... ....... .......... .................. .......... evic dB .. ...... .. .. ...................... ....... ..... ........ ..... ......... ... ApproVid .TW ................ ' ...............