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'�. REIMBURSEMENT REQUEST - UNDERGROUND STORAGE TANK CLEANUP FUND <br /> f CLAIMNO. 003359 REGION.- S REIMBURSEMENTNO. 1 <br /> ' CLAIMANT STEPHENS MARINE IN(. L <br /> CO-PAYEE. NONE <br /> CLAIMANTADDRESS: P.O.BOX 670 t <br /> STOCKTON, CA 95201 <br /> CONTAMINATED SITE: . STEPHENS ANCHORAGE <br /> ADDRESS: 4950 W_BROOKSIDE ROAD <br /> STOCKTON, CA 95219 <br /> M � <br /> TM •--•'-S•^,'S,501 TERFCDMMI -_ <br /> 0 <br /> PROJECT COSTS INCURRED-TO DATE `F ApPxoD Foci.. <br /> (This section to be completed by claimant) j PAI'MENT(Tp DATE) <br /> t <br /> (State Use Only) <br /> 1. CORRECTIVEACTIONCOSTS S55 9 22 ,'!36 <br /> (Costs entered here must be cumulative, <br /> total—to—date,NOTINCREMENTAL f i <br /> Sec Reimbursement Request Instructions) <br /> 2. THIRD PAR TYJUDGMENT $ � 0 o6 $ <br /> } ip. <br /> 3. DEDUCTIBLE (Subtract) ($10,000) <br /> $la oaa <br /> f <br /> TOTAL <br /> (Lines l,2&3) $ 45 '922. 36_- ...... .. . .. . _ . <br /> i CERTIFICATION: r <br /> ha ve read and agree with-the "Conditions of Payment"(Exhibit I),listed on the reverse side of this document. <br /> E: OTE: This request CANNOT BE PR OCESSED unless the "Conditions of Paymen t"are included on the <br /> _ everse side when submitted. <br /> .. .:yr��..-.. ' :4" _. -.." ;,ia,`-.'�s,T -.....:+Y -_4 ..:�--..ut:.�.4 i+�':iO.l'e"v:��..-__-�yF ,:� ii�''^°�; -"'hMt�W .–W .•iF;.;.p�F '+." _ <br /> The costs claimed have been incurred and have been paid or will be paid within thirty(30)days <br /> i of receipt of the funds requested hereby. If such costs have not been paid►within-1d days,funds received, <br /> under this request will be returned to the State Water Resources Control Board. .; <br /> i CLAIMANT SIGNATURE � i DATE J1z3 <br /> Stte e baUsp , <br /> Less <br /> ••- <br /> $27 <br /> proved For Payment to Date Previous Payments Amount ue <br /> Reye Title...; .. . <br /> Date <br /> Gf.�r # ,�. F�f . I <br />{ <br /> prpve By .. Title . Date. . . <br /> i '6 Form USTCF—REQ (Rev. 6/93) <br />