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<br />3Çv <br />SECTION 1. APPLICA TION <br /> <br />1. a. Applicant is: (complete applicable blanks) <br />Corporation, provide Tax ill No.(Texas or Federal Employee ill No.): <br />Partnership, provide names 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. Municipality <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 Former oymer 0 Former Operator <br />0 Lending Institution' 0 Insurance Agency <br />2. üst the Prirœ Contractor and/or Prime ColTective Action Specialist in the spaces listed below for which colTective 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: (-> <br />b. Prime ColTective Action Specialist N/ A <br />Mailing address: <br />Phone: (-> <br />3. üst the number of tanks, the size, and the contents of each tank at the facility for which reimbursement is being sought in this application. <br />If the tanks were removed and/or abandoned, note which ones were removed and/or abandoned and the date(s) they were removed from <br />- service: <br /> <br />Tank: Capacity Cootents (gasJline., diesel, etc.) - Remo=i and/or Abandoned Dale Remo=i I <br />No. (2:l1Ions) (ind..icate whícb) from Service <br /> <br />1 3,000 Diesel 1/91 3/89 <br /> <br />2 3,000 Diesel 1/91 3/89 <br /> <br />3 10,000 Gasoline 1/91 3/89 I <br /> <br />4 10,000 Gasoline 1/91 3/89 <br /> <br />5 <br /> <br />6 <br /> <br /> <br /> <br /> <br /> <br /> <br />TNRCC APPLICATION FOR REIMB URSEMENT E-Z FORM 2 <br />TNRCC~230-EZ (Revised 09~ 1-95) <br />