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REIMBURSEMENT REQUEST- UNDERGROUND STORAGE TANK CLEANUP FUND <br /> CLAIM NO: 006962 REGION: 5 REIMBURSEMENT NO: <br /> CLAIMANT. VILLAGE WEST MARINA <br /> CO-PAYEE: NONE <br /> JOINT CLAIMANT: NONE <br /> DWIGHT W. DA VIS <br /> CLAIMANT ADDRESS: 6649 EMBARCADERO DR <br /> STOCKTON. CA 95219 <br /> CONTAMINATED SITE. VILLAGE WEST MARINA <br /> ADDRESS: 6649 EMBARCADERO <br /> STOCKTON, CA 95219 <br /> LETTER OF COMMITMENT $70,000 AMENDMENT NO: 0 <br /> FOR <br /> PROJECT COSTS INCURRED TO DATE AODA <br /> ('Phis Section to be completed by claimant) PAYMMENTENT(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 /> 2. THIRD PARTY JUDGEMENT $ $ <br /> 3. ADJUSTMENT $ ( ) $ <br /> 4. DEDUCTIBLE (Subtract) $ (5,000) $�(5,000) <br /> TOTAL (Lines 1, 2, 3 & 4) $ I $ <br /> CERTIFICATION. L— <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 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 SIGNATURE: DATE: <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 />