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<br /> I <br /> SECTION I. APPLICATION <br /> I 1. a. Applicant is: (complete applicable blanks) <br /> I Corporation, provide Tax ill No.(Texas or Federal Employee ill No.): <br /> Partnership, provide nàmes and social security numbers for all partners: <br /> (name) (SSN) <br /> I (name) (SSN) <br /> Individual, provide Social Security No.: <br /> I Lending 1nstUuûon: Date of foreclosure <br /> Other: MDn~U~ <br /> b. Applicant is the: (check all that apply) <br /> .. X Tank system owner X Tank system operator <br /> I X Facility owner 0 Land owner <br /> 0 Fonner owner 0 Former Operator <br /> 0 Lending Institution 0 Insurance Agency <br /> I 2. Ust the Prime Contractor and/or Prime Couective Action Specialist in the spaces listed below for which corrective action activities were <br /> supenised and directed for the reimbursement billing period of this application: <br /> I a. Prime Conuactor: N/A <br /> Mailing address: <br /> I Phone: <--> <br /> b. Prime Co11'eCtive Action Specialist: N/A <br /> I Mailing address: <br /> Phone: L-> <br /> I 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 /> application. 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 /> I T- Capacity Contents (gasoline, diesel, etc.) Rermved and/or Abandoned Date Rermved <br /> No. (gallons) (indicate whieb) from Service <br /> I 1 3,000 Diesel 1/91 3/89 <br /> 2 3,000 <br /> Diesel 1/91 3/89 <br /> I 3 10,000 Gasoline 1/91 3/89 <br /> 4 10,000 Gasoline 1/91 3/89 <br /> I 5 <br /> 6 <br /> IJ <br /> I <br /> I 1NRCC APPUCA -nON FOR REIMBURSEMENT E-Z FORM 3 <br /> 1NRCC-O230-EZ (Revised 09-01-95) <br /> -- <br />