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REIMBURSEMENT REOWEST UNDERGROUND STORATPLwIANK CLEANUP FUND <br /> CLAIM NO. 009881 REGION. 5 REIMBURSEMENT NO. <br /> CLAIMANT. Pamela L. Lopez <br /> CO-PAYEE: None <br /> JOINT CLAIMANT: None <br /> CLAIMANT ADDRESS: P. O. BOX 393 <br /> Thornton, CA 95686 <br /> CONTAMINATED SITE: Residence <br /> ADDRESS: 26500 Nowell Rd. <br /> Thornton, CA 95686 <br /> LETTER OF COMMITMENT AMOUNT: $15,000 AMENDMENT: 0 <br /> PROJECT COSTS INCURRED TO DA TE 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 here must be cumulative, t <br /> total-to-date, NOT INCREMENTAL. <br /> See Reimbursement Request Instructions) <br /> 2. THIRD PARTY JUDGMENT $ <br /> 3. DEDUCTIBLE (Subtract) $. (0) _ $ (0) <br /> TOTAL (Lines 1, 2 & 3) $ $ <br /> CERTIFICATION. <br /> I 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,Rands received under this request will <br /> be returned to the State Water Resources Control Board. <br /> CLAIMANT SIGNATURE.- 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 /> Form USTCF-REQ(Rev. 6/93) <br />