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SI�Ie sf Cdi/prpirlSts+e Wu.r Rswt 'Coalml t3ap41 <br /> e.,iroaatalt,wl rrvtaiion,LRsarS Underground Storage Unit ClennnP Fund <br /> LETTER OF COMMITMENT <br /> DATA SKEET <br /> CLAIMANT: 407 <br /> CLAB4tN0 � <br /> CLAIM CONTACT"_ fELt;pi{pNE i�10.: <br /> The information.requested on this Form must be coalpleted i,vithin ten(10)working days of receipt of this form or the issuance of <br /> your tetter of Commitment may be delayed. it is important that the information provided be as accurarg alrd coMplEle as possible. <br /> Once a Letter of Commitment is issued and landing is committed to reimburse you for your eligible costs,you will be required to <br /> submit your first reimbursement reque.it within 90 calendar days from the date of the letter transmitting the Letter of Commitment. <br /> Failure to submit your reimbursement request within the 90 days will result in steps taken to withdi-aw your Letter of Commitment- <br /> 1. SITE STATUSICOSTS <br /> 1. INCURRED(PAST)COSTS: S <br /> DesCunit ACT%Vr MS(WORK CONDI o): <br /> 2. PROPOSED(FUTURE)COSTS: S (wmiwllifiNRxT 6 AmflNTIIs) <br /> p,rscP.tnF AcTivmrs(PROPDSED WORK): <br /> NOTE: THEiNiTi.\LA%tOtI.tiTOFY4URLrTrEROFCO%I%iT11CwTWILr.I#E9.15FDSUCSTAA"r1AIIVUPOVTUF.INYt10.1IATtpVYOUSUPPl.)'AilO%T. YUVAIAV <br /> PROVIDE ADDITIONAL I`IFORSJAVOY REGARDING THE CORRF.C`rrl,'£ACnON ACTIVITITSW4 VIF ii,kcKOrTn15 ruaM. VAII,UR£TO COMPLETE Tills <br /> INFOILSIATI08 wil.LDFLAym1F.AwARDOFYOUR Le7TBIRorCoA0411T51F.,Yr. <br /> 11. INCURRED COST SUMMARY <br /> LIST A COMPI.6'rIG$11h141rtRY OF L -IGINt.Is C4xR1iC'JTvE ACnON COSTS INCURRED TO DATE, DO NOT INCLUDE TANK RWOvAL COSTS,ATTORNEY <br /> FFCS OR APPLICATION PREPAttATlON COsTs- AT THIS TIME,YOU ARE NOT REQUIRED TO SUBMIT THE ACTUAL 14VOICES OR LIST rNDIVIDUAL <br /> INVOICES. LIST THE FW.X S AND THE TOTAL COSTS FOR EACH FiRm. AN FXAMIPLU SU?4mAKY lS t ROVIDED UE40 W; <br /> Elm TOTAL AMQUNT <br /> f $9�I 57 .00 <br /> NOTE:�OrJLY LIST THOSE riR?IS wiiie'it ltAvf.ACTUAIJ.Y INYolC'ED i'OU. Do s.OT f.IST P$OPOSALS. DO NOT LISP SUBCONTItA6TOttl 1tilIU-SF.III LLS ARE <br /> ALREADY INCLUDED 1,4M(E PlIIA1E GONSULTANT�CONTRAC.TOR ItiVOICL. <br /> COMPLETED BY: DAIT:: _ <br /> CLAIMANT 271iiNXIVIURC: DA'rE: <br /> lzr,rtJRN COMPLETED FORM TO: -..._..._....... ...... <br /> State W.atel Rescurce's Control Board,P.O. Bwi 944212,Sacramento,CA 94244-2120 or FAX (916)227-453@ <br /> Md 0h7-'ON 82TO a9b60Zti6 F QNnJ dnNti31D 1Sn S17:T T 2.6180120 <br />