Res 1995-183 - Laserfiche WebLink

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I 33~ I 11. Provide the following information in order to calculate the total reimbursement request for this application: I a. From the Reimbursement Claim Summary (Section V). provide the total cost for correctiv,e action performed: """""""""""""""""""""""""""$:12,.915.60' I b. Enter the required deductible amount if this is the first reimbursement claim: ",,:"":,,:'::,,""""""',' " ", ", " , I {Same as line (lO.c.)}: .......................................$":::N/A I' c. For the corrective action expenses requested to be reimbursed in this application. provide the amount of any private insurance reimbursement that has already been received for these expenses or for which a claim was flIed prior to July 17, 1990: I "" "" . .....................................................~¡?;!!:::?'!"'}::':'~/A'i.~¡'¡:::' ,::}t;1¡.: , Insurer name: - Policy number: As of I I (date). insurance reimbursement has been (check ope): 0 received 0 claimed : TOTAL REIMBURSEMENT REQUEST (ll.a.) - (ll.b.) - (11.e): ... . . . . . . . .1~f:ÎJ~~ig~;L{~ . 1 12. Proof of payment for all claimed expenses must be included for each application submitted for reimbursement. , Evidence of proof of payment may include the following items: , : . Business receipts or invoices from the person who perfoí:med the work. indicating payments received; . Canceled checks (copies, front and back); , . An affidavit signed by the, person who performed the work affirming that the amounts which the applicant represents as being paid to him were paid in full. If the contractor has accepted a promissory note as .payment.. a copy of the Promissory Note must be submitted with the affidavit; or , . The certification of a certified public accountant that the expenses for which reimbursement is requested have been paid in full. , 13. § NO All of the petroleum storage tanks that are subject to registration requirements are registered with the , TNRCC and ail annuaÌ tank regist~ti~n fees d~e since Sep~ember I, 1987, have .been paid in full. (please - note that ail fees owed must be paId m full pnor to the disbursement of the reImbursement check.) I 14. YES @ave new tanks been installed at this site? If yes. when: I I , TNRCC APPUCATION FOR REIMBURSEMENT B-Z FORM 7 TNRCC-Q230-EZ (1l~1-94)