Res 1995-183 - Laserfiche WebLink

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-- . 33/J I 11. Provide the following infonnation in order to calculate the total reimbursement request for this application: , a. From the Reimbursement Claim Summary (Section V), provide the total cost for corrective action performed: I I ...............................................,......$ 18.032.35 j b. Enter the required deductible amount if this is the first reimbursement claim: 1 {Same as line (IO.c.)}: ...................................... .$. H,,:':NI A. j : c. For the corrective action expenses requested to be reimbursed in this application, provide the amount of any private l insurance reimbursement that has already been received for these expenses or for which a claim was filed prior to July 17, 1990: j ..;::..' ""'. ./.'.'...'.';.', ..'.' .:.,.,. .....................................................~';.::N.fÁ'~::.;.':.::./{::.;~ ... .. ~ . H"" ';;'." ........,... '.'., '.'.' ì Insurer name: ì Policy number: As of 1 1 (date), insurance reimbursement has been (check one): 0 received, 0 claimed 1 i I~ . '.' "". ,'I I TOTAL REIMBURSEMENT REQUESI' (ll.a.) - (ll.h.) - (ll.e): . . . . . . . . . .. . i~ ,ò~ij;~ .". , t 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: t . Business receipts or invoices from the person who performed the work, indicating payments received; . Canceled checks (copies, front and back); t . AIl 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 ftpayment", a copy of the Promissory Note must be submitted with the affidavit; or t . The certification of a certified public accountant that the expenses for which reimbursement is requested have been paid in full. I 13. 81 NO All of the petroleum ~torage tanks that are subject to registration requirements are registered with the I TNRCC and all annual tank registration fees due since September I, 1987, have been paid in full. (Please note that all fees owed must be paid in full prior to the disbursement of the reimbursement check.) 14. YES Gave new tanks been installed at this site? If yes, when: / / TNRCC APPLICATION FOR REIMBURSEMENT E-Z FORM 7 TNRCC-D23Q-EZ ("{)1-94)