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<br />'-~-~~, <br /> <br />I ç~ <br />SECTION I. APPLICATION <br /> <br />1. a. Applicant is: (compl~te applicable; blanks) - <br />Corporation, provide Tax ill No.(T e;Xas or Fc;deral Employee ill No.): <br />Partnership, provide names and social security numbers tor all partners: <br />(ruune) (SSN) <br />(ruune) (SSN) <br />Individual. provide Social Security No.: <br />LeIJding Institution: Date of foreclosure <br />Other: Mllnirip>1lity <br />Applicant is the: (check all that apply) <br />X Tn"!.- <;y<;tprn o'\.\.'1'Ipr X T>1"!.- <\yqprn oppratoc <br />X Farility ownpc Land owner <br />Former owner Former Operator <br />Lending Institution .' Insurance Agency <br />2. List the Prime Contractor arul/or Prime Corrective Action Specialist in the spact::s listed below tor which corrective action activities <br />were supervised and directed for the reimbursement billing period of this application: <br />a. Prime Contractor: N I A <br />Mailing address: <br />. <br />Phone: (--.J <br />b. Prime Corrective Action Specialist: N I A <br />Mailing address: [ <br />Phone: L-J t <br />3. List the number of tanks, the size, and the contents of each tank at the facility for which reimburse;ille;nt is being sought in this t <br />application. If the tanks were removc;d and/or abandoned, note which ones were removed and/or abandouc;d and the date(s) they were <br />removed from service: <br /> <br />~ c..pacity Contents (gasoline. diesel. etc.) Removed and/or Abandoned I Date Removc:-d <br />Nt (!allons) (indicate which) from Servic.: <br /> <br />I 3,000 Diesel 1/91 .' I 3/89 <br />2 3.000 Diesel 1/91 3/89 , <br />í <br />3 10.000 Gasoline 1/91 3/89 <br />4 10.000 Gasoline 1/91 3/89 <br />5 <br />6 I I <br /> <br />) <br />I <br />I <br /> <br />! <br />,I <br />r <br />I <br />~- <br /> <br />! <br />'i'RCC A.PPUCATION FOR REIMBURSE.\.1ENT E-Z FOR.\1 2 <br />,<'RCC-O23O-EZ (Revis"d 09-01-95)- <br />.l <br />