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REIMBURSEMENT REQ/EST- UNDERGROUND STORAGE TANK CLEANUP FUND <br /> CLAIM NO. 008477 REGION: 5 REIMBURSEMENT NO. <br /> CLAIMANT.- Mr. Elwood Alberg <br /> CO-PAYEE: Mr. Fred Alberg <br /> JOINT CLAIMANT.• <br /> CLAIMANT ADDRESS: P.O. Box 575 <br /> Lodi CA 95241 <br /> CONTAMINATED SITE: Delta Pub <br /> ADDRESS: 13430 Lower Sacramento Road <br /> Lodi CA 95240 <br /> LETTER OF COMMITMENT AMOUNT.• $20,000 AMENDMENT: 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 /> See Reimbursement Request Instructions) <br /> 2. THIRD PARTY JUDGMENT $ / $ <br /> 3. DEDUCTIBLE (Subtract) $ (5,000) $ (5,000) <br /> TOTAL (Lines 1, 2 & 3) $ $ <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 <br /> reverse side 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 <br /> funds requested hereby. If such costs have not been paid within 30 days,funds received tinder this request will <br /> be returned to the State Water Resources Control Board. <br /> CLAIMANT SIGNA TURF: DA TE: <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 /> Form USTCF-REQ(Rev. 6/93) <br />