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REIMBURSEMENT REQUEST- UNDERGROUND STORAGE TANK CLEANUP FUND <br /> CLAIM NO: 007301 REGION: 5 REIMBURSEMENT NO: <br /> CLAIMANT.• LLOYD GUMS <br /> CO-PA YEE.- NONE <br /> JOINT CLAIMANT.- NONE <br /> CLAIMANT ADDRESS: 731 BIRCHWOOD DR <br /> LODI, CA 95240 <br /> CONTAMINATED SITE. LLOYD'S MOTORS <br /> ADDRESS: 303 CHEROKEE LN S <br /> LODI, CA 95240 <br /> LETTER OF.COMMITMENT $30,000 AMENDMENT NO: 0 <br /> PROJECT COSTS INCURRED TO DA TE APPRO RSR <br /> (This Section to be completed by claimant) PAYdN�1TT(Tft D. �'E) .: <br /> (fie ase Qeat,�) <br /> I. CORRECTIVE ACTION COSTS $ <br /> (Costs entered here must be cumulative, <br /> Total-to-date, NOT INCREMENTAL.) <br /> 2. THIRD PARTY JUDGEMENT $ $ <br /> 3. ADJUSTMENT $ ( ) $ <br /> 4. DEDUCTIBLE (Subtract) $ (5,000) $ r ..... <br /> TOTAL (Lines t, 2, 3 & 4) $ $ <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 reverse side <br /> 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 funds <br /> requested hereby. If such costs have not been paid within 30 days,funds received under this request will be returned to the <br /> State Water Resources Control Board. <br /> CLAIMANT SIGNA TORE. 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 /> Lott Yresno Jlreel 4LJU WC]IIQII MVC.JUILU IU:J <br /> Fresno,CA 93716 Modesto,CA 95256 Visalia,CA 93292-6710 Bakersfield,CA 93308 V <br /> (209)268-7021 •Fax 268-7126 (209)545-1050•Fax 545-1147 (209)625-1712•Fax 625-1714 (805)393-5088•Fax 393-4643 <br />