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a <br /> -r" <br /> REIMBURSEMENT REQUEST- UNDERGROUND STORAGE TANK CLEANUP FUND j <br /> CLAIM NO: 011461 REGION: 5 REIMBURSEMENT NO:, <br /> CLAIMANT.- JOHN GEMELOS <br /> CO-PA YEE. NONE <br /> JOINT CLAIMANT.- NONE <br /> CLAIMANT ADDRESS.• 456 ROLL YWOOD <br /> TRACY, CA 95376 <br /> CONTAMINATED SITE: PALADIN MILEAGE CENTER x <br /> ADDRESS: 2421 HOLLY DR <br /> TRACY, CA 95376 <br /> LETTER OF COMMITMENT $25,000 AMENDMENT NO: 0 <br /> PROJECT COSTS INCURRED TO DATE APPRoVED FOR <br /> PAYMENT(TO DATE) <br /> (This Section to be completed by claimant) ' <br /> :(State Use Only.) 1 <br /> i <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 9,.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 j <br /> requested hereby. If such costs have not been paid within 30 days,funds received under this request will be.returned to the <br /> i <br /> State Water Resources Control Board. y <br /> CLAIMANT SIGNA TURF: DA TE: <br /> STATE USE ONLY.:APPROVAL.FORPAYMENTS <br /> $ LESS $ $ <br /> Approved for' Payment to Date `. Previous Payments : Amount Due <br /> Reviewed By Title: Date <br /> Approved By: i- Mle: Date: <br />