Laserfiche WebLink
_ NOV 0 2 1993 <br /> REIMBURSEMENT REQUEST - UNDERGROUNDAT01�4 ''TANK CLEANUP FUND <br /> CLAIMNO. 001695 REGION. S REIMBURSEMENTNO. 1 ' <br /> CLAIMANT• CANEPA'S CAR WASH <br /> CO—PAYEE. NONE <br /> /53�. <br /> CLAIMANTADDRESS. 4542ND.HUNTER ST. <br /> STOCKTON, CA 95204 <br /> CONTAMINATED SITE. CANEPA'S CAR WASH <br /> ADDRESS: 642 NO. HUNTER ST. <br /> STOCKTON, CA 95202 <br /> E=R OF COMMITMENTAMO UNT: $50,000 AMENDMENT:0 <br /> PROJECT COSTS INCURRED TO DATE APPROVED FOR a <br /> (This section to be completed by claimant) PAYMENT(TO DATE) <br /> (State Use Only) <br /> 1- CORREC77VEAC'170NCOSTS $ 31GG $ <br /> (Costs entered here must be cumulative, <br /> total—to—date,NOTINCREMENTAL <br /> See Reimburscmcnt Requcst Instructions) <br /> 2. THIRD PARTY JUDGMENT j $ $ <br /> 3. DEDUC77BLE (Subtract)/ ($10,000) ($10,000 <br /> i <br /> TOTAL (Lines 1,2&.3) % $ /. 2 $ <br /> CERTIFICATION: <br /> have read and agree with the "Conditions ofp��ent"(Exhibit I), listed on the reverse side of this document. <br /> OTE: This request CANNOT BE PRO ESSED unless the "Conditions of Payment"are included on the <br /> everse side when submitted. <br /> The costs claimed have been incurred a d have been paid or will be paid within thirty(30) days <br /> of receipt of the funds requested here y. If such costs have not been paid within 30 days,funds received <br /> under this request will be returned t the State Water Resources Control Board. <br /> CLAIMANT SIG NAT RE: DATE: lo --ey-yam <br /> State Use Only.Approval for:Payment <br /> $ _ Less: $ <br /> pproved For Pavment to Date ' Pre viousPayznents ` Amount Due <br /> Reviewed By.- % Title: Date: <br /> pproved By. Title: Date: <br /> Form USTCF—REQ (Rev. 6,93) <br />