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<br /> SECTION I. APPLICATION <br /> 1. a. Applicant is: (complete applicable blanks) <br /> Corporation, provide Tax ID No.(Texas or Federal Employee ID No.): <br /> Partnership, provide nàmes and social security numbers for all partners: <br /> (name) (SSN) <br /> (name) (SSN) <br /> Individual, provide Social Security No.: <br /> Lending Institution: Date of foreclosure <br /> Other: MunKïpaUty <br /> b. Applicant is the: (check all that apply) <br /> X Tank system owner X Tank system operator <br /> X Facility owner 0 Land owner <br /> 0 Fonner owner 0 Former Opet:ator <br /> 0 Lending Institution 0 Insurance Agency <br /> 2. list the Prime ContI3ctor and/or Prime CoIreCtive Action Specialist in the spæes listed below for which coITeCtive action activities were <br /> supervised and directed for the reimbursement billing period of this application: <br /> a. Prime Contractor: N/A <br /> Mailing address: <br /> Phone: L-J <br /> b. Prime Corrective Action Specialist: N/A <br /> Mailing address: <br /> Phone: L-J <br /> 3. List the number of tanks, the size, and the contents of each tank at the facility for which reimbursement is being sought in this <br /> apptication. If the tanks were removed and/or abandoned, note which ones were removed and/or abandoned and the date(s) they were <br /> removed from service: <br /> Tank Capacity Cootents (gasoline, diesel, etc.) ReJmvcd and/Œ Abandœed Date ReIIDved <br /> No. Üzallons) (mcate which) from Service <br /> 1 3,000 Diesel 1/91 3f89 <br /> 2 3,000 Diesel 1/91 3/89 <br /> 3 10 ,000 Gasoline 1/91 3/89 <br /> 4 10 ,000 Gasoline 1191 3/89 <br /> 5 <br /> 6 <br /> 1NRCC APPUCA TION FOR REIMBURSEMENT E-Z FORM 3 <br /> 1NRCC-O23O-EZ (Revised 09-01-95) <br />