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MailingAddress W +    C  City,State  W +  ZipCode  W +  ContactPerson M!!   9 # Phone  M!$ Fax#X0X,, #  M!% aXX0ApplicantIsthe: C& TankOwner0 @ 0@H&@H&TankOperator0H H&H&0H H&H H&FacilityOwner0PH&H&0PH&PH&LandOwner0XH&H&0XH&XH&FormerTankOwnerS(H&H& FormerTankOperator0  FormerFacilityOwner0H&H&FormerLandOwner#X0Xa\ # 4dddd!*H&H& 94aXX0 AgentorAssigneeInformation #X0Xay #aXX0Ԁ(IfthereisanAgentorAssignee,CompleteandIncludeAssignment)#X0Xa # 0& + 9 dddd 0, ,XX0AgentorAssignee#X0X,, # &,   p- , ,XX0MailingAddress .   0 City,State  1 ZipCode  2 ContactPerson 3   5 Phone  6 Fax#X0X,,  #  7 aXX0AgentorAssigneeisthe: 8 Insurer0  0@H&H&0@H&@H&LendingInstitution0H H&H&0H H&H H&PurchaseroftheProperty0H&H&PurchaseroftheTanks0H&H&D:H&H& Contractorwhoperformedworkatsiteandisfinancingcorrectiveaction#X0Xa<# %dddd T< % aXX0SiteInformation#X0Xa&# +!=dddd +, ,XX0FacilityName  >   Z!. ? FacilityAddress d"8!@   P#$"B City,State  d"8!C ZipCode#X0X,, #  d"8!D , ,XX0_LPST_ԀIDNumber Z$.#E   F%$G FacilityRegistrationNumber  Z$.#H OwnerIDNumber#X0X,, # "dddd Z$.#I " aXX0PayeeIdentificationNumbers#X0XaȚ# 'P&$%Jdddd 'aXX0Applicant 'V&K FederalEmployersIdentification(_FEI_)Number ('M SocialSecurityNumber(_SSN_) \)0(N ComptrollersAssignedNumber#X0Xa"# )(O aXX0TexasTaxpayerNumber#X0Xa~#  *l)P aXX0Number:#X0Xa#___________________________________________________  F*)T aXX0AgentorAssignee +*U FederalEmployersIdentification(_FEI_)Number -+W SocialSecurityNumber(_SSN_) -x,X ComptrollersAssignedNumber#X0Xaȋ# B.-Y aXX0TexasTaxpayerNumber#X0Xa#  .-Z aXX0Number:#X0Xag#___________________________________________________.b-^    /.^  OWNER/OPERATORCONTRIBUTIONORDEDUCTIBLE ,  @Arequiredowner/operatorcontributionor"deductible"mustbemetbeforecostscanbereimbursed.Therequired D deductibleisbasedon: k?   0  howmanysinglepetroleumstoragetankstheapplicantownsoroperatesinTexas;f&&   0  ifspecificcorrectiveactionmilestonesaremet;and&&   0  thenumberofoccurrenceswhentheapplicationisdeterminedtobeadministrativelycompleteatthe  _TCEQ_.&& @0  AninitialdeductibleisrequiredforeachOccurrence(_LPST_ԀIDNumberthedeductiblemayincrease .  baseduponthefailuretomeetspecificcorrectiveactionmilestones). Thedeductible,or"owner/operator   contribution"willbeasfollows: ~ && T*U+ dd[dd [ dd  " dd " V,&,&,E d ,gtd ,-td ,td ,\t +  6'V * V *  6@OOaXX0NUMBEROF   @ SINGLE  a  @66PETROLEUM   @STORAGETANKS   @APPLICANTOWNS : @ OR  @""OPERATESIN X, @ TEXAS ;V,! ;@ , REQUIRED   @q q , DEDUCTIBLE  a  @ , ($) ;V,! V ; @WW#FAILURETO   @$SUBMITA  a  @]]&SITE   @<<#ASSESSMENT   @$PRIORTO : @$12/23/96 2V#V 2 @1FAILURETO   @~~3SUBMIT  a  @1ANDRECEIVE   @2APPROVAL   @5FOR :! @1CORRECTIVE " @1ACTIONPLAN X,# @==2PRIORTO $ @36/23/98 6V#vJ%V 6 @@ FAILURETO  & @C MEET  a ' @? THEGOALSIN  ( @? THEAPPROVED  ) @@ CORRECTIVE :* @@ ACTIONPLAN + @9 9 D BY X,, @A 12/23/99 JV;#-  V <J#X0Xa# PXX0lessthan13tanks; 2VV#p.V 2@0 0 , $1,000 2VV#p/VV 2@%$2,000 2VV#p0VV 2@3$4,000 6VV#p1VV 6@B $8,000 JV;#p2 < VV <J13to99tanks,inclusive; 2VV#3V 2@0 0 , $2,500 2VV#4VV 2@%$5,000 2VV#5VV 2@uu3$10,000 6VV#6VV 6@B $20,000 JV;#7 < VV <J100to999tanks,inclusive;or 2VV#48V 2@0 0 , $5,000 2VV#49VV 2@%$10,000 2VV#4:VV 2@uu3$20,000 6VV#4;VV 6@B $40,000 JV;#4< < VV <J1,000ormoretanks. 2VV#T=V 2@  , $10,000 2VV#T>VV 2@%$20,000 2VV#T?VV 2@uu3$40,000 6VV#T@VV 6@B $80,000 NV;#TA < VV lNIfasitehasreceivedaclosureletteronorafter9/1/95#X0X P[%# PXX0Ԁandhasasubsequentrelease,thedeductiblewillbe$50,000.6,*B 0 l  V 60   && 0  NumberofsinglepetroleumstoragetanksownedoroperatedinTexasbyapplicant:_______________________________________&&R&&& \0C 0  Enterrequireddeductible:hE&& *,- ddE d E gtd g-td -td \t \U+,&,&,l , +  1'0F0 h10  0040 440      0  0040 44#A.   # )@ H )$___________________3)'J h @ 30  Forthecorrectiveactionexpensesrequestedtobereimbursedinthisapplication,providetheamountofanyprivateinsurance ,K reimbursementthathasalreadybeenreceivedfortheseexpensesorforwhichaclaimwasfiledpriortoJuly17,1990:L&& *r]^ ddl l ,-,&,&r,l , +  1'd8Md8 h10  0040 440      0  0040 44#A.   # )@ O )$___________________3)'Q h @ 3    Insurername:&&R& ` 4R     Policynumber:&&R& !l T 0    Asof________/________/________(date),insurancereimbursementhasbeen(checkone):receivedclaimed"!V&&  Thetotalcostssubmittedintheapplicationforreimbursementistobereducedbythedeductibleamountandanyamountof $"X reimbursementreceivedfromaprivateinsurer: $w#Y *r_` ddl l ]^,&,&r,00 ,00 +  1t&H%\t&H% 01#X0X P3,# *(83."/3"  /372  A  .3  0    TotalCostofActivitiesSubmittedinthisApplication: PXX0/377݌&x%] Ќ  8@#!`'4&^ 8$ @-?'&` 00 @ 0@"/3"  /3)92  B  .3  0    DeductibleAmount:/3)9V9݌(V'a Ќ  8@#!)'b 8$ @-)'d 00 @ 0@"/3"  /3~:2  C  .3  0    ReimbursementreceivedfromInsurer:/3~::݌?*)e Ќ  8@#!*)f 8$ E2*)h 00 @ 0ED.0  0 0d  TOTALREIMBURSEMENTREQUEST(A)(B)_(C_):#A.  =dd# A@,!,k+j A$___________________3)',l+l 00   @ 3#X0X PJ8#   (.,m T T,,X, T  TRX3'Avery 12-294/295 Laser TaX3' Letter3'Avery 5159 Addressser TaX3'3'LetterT*x?VMdd00 00 _`,&,&x,%dd +  $ddd,, $  REIMBURSEMENTAFFIDAVIT  d    PXX0Stateof________________#X0X P@# PXX0 L     @     Countyof_______________ V #X0X Px@#aXX0 #X0XaCA# PXX0 BEFOREME,theundersignedauthority,onthisdayappeared_______________________________,knowntobethepersonwhosename o issubscribedtothefollowinginstrumentandhavingbeenbymedulysworn,uponhisoathdeposesandstatesasfollows: 7    Mynameis_____________________________.Iamovertheageofeighteen(18)years,amanadult,andamcompetentandable  totestifyherein.Iamfullyawarecognizant,andhavepersonalknowledgeofallfactssetforthinthisaffidavit,andamabletoswear,andI oC  _do_Ԁswear,thatallfactsandstatementshereincontainedaretrueandcorrect.    Thisaffidavitpertainstothefollowing: C   _LPST_ԀIDNo: ___________________0 H 0H H&H H&0H&H&0PH&H& 򀀀RequestedAmount: _________________{ OPH&PH& FacilityAddress:_________________________________________________________   City________________________County_______________________________,Texas   #X0X PA#aXX0  #X0XaȭF# PXX0Icertifythatthisreimbursementapplicationandallattachmentswerepreparedundermydirectionorsupervisionandthatqualifiedpersonnel  w  properlymanagedorperformedapplicableremedialactivitiesand/orgatheredandevaluatedtheinformationsubmitted. ?  Iaffirmthatthisclaimdoesnotseekreimbursementforthelease/rentalorthepurchaseofanyequipmentforwhichtheeligiblepurchasecost wK hasalreadybeenpaidfromthePetroleumStorageRemediation(_PSTR_)Accountaspartofareimbursementclaimpertainingtothisoranyother  _LPST_Ԁsite,orforwhichtheeligiblepurchasecostiscurrentlybeingclaimedaspartofanotherpendingreimbursementclaimpertainingtothis  oranyother_LPST_Ԁsite. K IagreetoreturntotheTexasCommissiononEnvironmentalQuality(_TCEQ_),uponitsdemand,alloranypartofthereimbursedamount,asthe W _TCEQ_Ԁconsidersappropriate,ifIknowinglyfalsified,misrepresented,oromittedanyfactrelevanttothedeterminationsmadebythe_TCEQ_Ԁor  theExecutiveDirector,oralorwritten.  Astheclaimantforreimbursementfromthe_PSTR_ԀAccount,IcertifythatIhavepaid,orensuredpaymentthroughthepostingofabond,all ! contractorsand/orsubcontractorsincompliancewithTitle30,TexasAdministrativeCode(TAC),334.306(b)(7),334.306(b)(10),and c" 334.309(d)#X0X PF# PXX0.Ifurthercertifythat:(clearlymarkoneofthefollowing): +# ____0  IamtheeligibleowneroroperatorofthereferencedLeakingPetroleumStorageTank(_LPST_)siteasdescribedatTitle30TAC c7% 334.304.IhavepaidallamountsowedtotheprimecontractorinfullorIhaveensuredthatthoseamountswillbepaidinfullthrough & thepostingofapaymentbondintheamountnotyetpaidinfull;oro'H&H& ____0  Iamaninsurerwhohaspaidclaimsforremediationcostsforthereferenced_LPST_Ԁsiteorapersonwhoholdslegalorequitabletitle ) tothereferenced_LPST_ԀsitewhohasbeenproperlyassignedtherighttoacceptpaymentonbehalfofthatowneroroperatorunderTitle oC* 30TAC,334.302(j)&(k).Thecompleteassignmentdocumentissubmittedwiththisapplicationorisonfilewiththe_TCEQ_.Ihave  + paidallamountsowedtotheprimecontractorinfullorIhaveensuredthatthoseamountswillbepaidinfullthroughthepostingofa {, paymentbondintheamountnotyetpaidinfull;orC-H&H& ____0  Iamproperlyregisteredwiththe_TCEQ_Ԁasa_LPST_ԀCorrectiveActionSpecialistinaccordancewiththerequirementsofTitle30,TAC, {O/ Chapter334,_Subchapter_ԀJ.Ihavebeenhiredbytheeligibleowneroroperatorofthereferenced_LPST_Ԁsitetoperformcorrectiveaction 0 activitiesandhavebeenproperlyassignedtherightbythatowner/operatortoacceptpaymentonbehalfoftheowneroroperatorunder 1 Title30,TAC,334.302(j)&(k).Thecompleteassignmentdocumenthasbeensubmittedwiththisapplicationorisonfilewiththe O#2 _TCEQ_.Ialsoaffirmthattheeligibleowneroroperatorofthereferenced_LPST_Ԁsiteisawareoftheworkperformedandtheamounts 3 requestedforthisapplication.IhavepaidallamountsowedtothesubcontractorsinfullorIhaveensuredthatthoseamountswillbe  [4 paidinfullthroughthepostingofapaymentbondintheamountnotyetpaidinfull.#!5H&H& F________________________________________________________________________________ ["/!7 SignaturePrintedName "!8 _________________________________________________________________________________ $#; CompanyName(ifapplicable)Title(ifapplicable) g%;$< 5 P#5X+X54N#5X5X+Subscribedandsworntobeforemetheundersignedauthorityonthis___________________day '&@ of_______________,20___,tocertifywhichwitnessmyhandandseal. s(G'A #5X+X5%[#5