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<br />TEXAS NATURAL RESOURCE ;-'8 <br />~ CONSERVATION COMMISSION <br />-J -- - <br />:' -= <br />- - <br />- -- <br />..~ PETROLEUM STORAGE TANK <br />J . 1"': REMEDIATION FUND <br /> <br />1 THRCC APPLICATION FOR REIMBURSEMENT <br />- E-Z Form <br /> <br />Protecting Texas <br />by Reducing end <br />? Preventing Pollution <br />J ALL BLA.'\"KS .:'>æST BE COMPLETED. If an item doe;; not apply write "NA". INCOMPLETE APPLICATIO!'lS <br />WILL BE RETUR."'~. Refer to Guidance Manual RG-174 for instructions. . <br /> <br /> <br />1 <br /> <br />Applicant (Company): ('ity of S:m M:!rco~ <br />I <br />! Contact Person: Fr:!ncp<; PJ()('pk <br /> <br />Phone:'(5l2) J9~-SOOlí Fax: (512) J92-2lí2:=; <br /> <br />Mailing Address: tí~O F}!~t Hopkin~ <br /> <br />(City) S:!n Mffrco<; (State) T'( (ZIP)7Slílílí <br /> <br />Facility Name: <br /> <br />Facility Address: fi10 F.:}~t Horkin~ . <br /> <br />(City) S:m M:!rC'o<; (State) T'( (ZIP)7Sñóó <br /> <br />County: H2Y~ <br /> <br />Lealång Petroleum Storage Tank (LPST) ID No.: 92líSO <br /> <br />TNRCC UST Facility Registration No.: 21líRO <br /> <br />TNRCC UST Owner Registration No.: <br /> <br />Is this the first request tàr reimbursemem for this release? No If no, how many previous claims <br /> <br />have been submitted ----.1L and total costs of all previous claims $ 2 J 007 ,~ 14 Total <br /> <br />Cost of this Application (SCCÛOQ V) $ 20, 7.~~ fió <br /> <br />Total Reimbursement Request (Section M$ 20, 7S"i lílí"- <br /> <br />Number of single petroleum storage tanks owned or operated in Texas: ~ <br /> <br />Check here if the TNRCC has preapproved the work described in this application. The TNRCC .",ill <br />reimburse only those costs that have been preapproved by the ægion inspector/RPR coordinator. <br />(Preapproval docum~ntation must be submitted with this application.) <br /> <br />Submit the original completed Application For Reimburs~m~nt including all Scht:dule A worksheets to: <br />Texas Natural Resource Cons~rvation Commission - <br />Reimbursem~nt Section. MC 1 39 <br />Petrol~um Storage Tank Division <br />P.O. Box iJ087 <br />Austin. Texas iS7 1 1-3087 <br />(512)239-2001 <br /> <br />Submit one copy of this Application to the appropriate TNRCC Regional FidJ Office. <br />