CCP 10-19-1995 - Laserfiche WebLink

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I . '. I. INDIVlDUAL CUlM FORM FOR REIMBURSABLE AMOUNTS FOR OAK GROVE SITE DISTRIBUTEES I 1. Locate the name of the Distributee completing this form on - the attached charr titled Calculation of Payments, I enter the amount lisred for that Distributee in the column tirled Total on this line: S 26,000 I 2. On a separate sheet of paper [FOR YOUR FILES ONLY if the monies received are subject to a confidentiality clause] I write down all monies received tDward eligible response costs from other sources for the Oak Grove contribution listed in item 1. I 3_ Calculate [FOR YOUR FILES ONLY if there is a confidentiality clause] the(l1onies you have received from other sources toward eligible response costs for the Oak Grove contribution listed in I item I above, and subtract the sum recei ved from the amDunt in item 1. The S tate defines eligible costs to exclude legal and administrative expenses; therefore, if you have been paid for sueh I expenses, the'sums paid toward such expenses should be recorded for your files but should NOT be included. I- 4, Enter On this line the amount of money you want the Oak Grove Trust to claim On your behalf as eligible response costs not already paid by another source. This should be a sum equal to 26,000 I Item ( I) less Item (3): S I HEREBY CERTIFY that the dollar amount listed in item No, 4 above is the I true, accurate. and complete dDllar amount that the Oak Grove Trust is authorized under the Landfill Cleanup Program to claim On behalf of I The City of Arden Hills as_the elIgIble response cost reImbursement claIm of saId entIty_ I ~~ - By: - . Its: I For: The City of Arden Hills I Subscribed and sworn to before me I this /S+-lJ day of IJc frJ h-<? y-- , 1995 ~ d! ?c.'? ru~:(IJ ~j5bJ./}6/J.f Ie e JULIANNE M, TOSTENSON . otary Public . NOTARY PUBLIC - MINNESOTA ~ .;' MyComm. EJ(~lIresOl/31/2000 299n2095475 10113/95 I