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REIMBURSEMENT REG,, ,.ST - UNDERGROUND STORAX.w TANK CLEANUP FUND <br /> CLAIM NO. 010086 REGION.- 5 REIMBURSEMENT NO. <br /> CLAIMANT. Carl A. Bennett <br /> CO-PAYEE: None <br /> JOINT CLAIMANT.- None <br /> CLAIMANT ADDRESS: 11146 Walnut Avenue <br /> El Monte CA 91731 <br /> CONTAMINATED SITE: Residential <br /> ADDRESS: 443 Sycamore Avenue <br /> Manteca CA <br /> LETTER OF COMMITMENT AMOUNT. $10,000 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 Isere must be cumulative, <br /> total-to-date, NOT INCREMENTAL. <br /> See Reimbursement Request Instructions) <br /> 2. THIRD PARTY JUDGMENT $ � <br /> 3. DEDUCTIBLE (Subtract) $ (01 _ $ (0) <br /> TOTAL (Lines 1, 2 & 3) $ $ <br /> CERTIFICATION: <br /> 1 have read and agree with the "Conditions of Payments" (Exhibit 1), 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 under this request will <br /> be returned to the State Water Resources Control Board. <br /> CLAIMANT SIGNA TURF: DA TE.- <br /> STATE <br /> E:STATE USE ONLY.- APPROVAL FOR PAYMENTS <br /> $ LESS: $ _ $ <br /> Approved for Payment to Dare Previous Payments Amount Due <br /> Reviewed By: Title: Date: <br /> Approved By: Title: Date: <br /> Form USTCF-REQ (Rev. 6193) <br />