LOUISIANA MOTOR FUELS UNDERGROUND STORAGE TAN路易斯安那汽车燃料的地下储罐.docVIP

LOUISIANA MOTOR FUELS UNDERGROUND STORAGE TANK TRUST FUND REIMBURSEMENT APPLICATION PART 1 SITE IDENTIFICATION FOR DEQ OFFICE USE ONLY DATE RECEIVED/DATE TO BE ENTERED ON EDMS TF No. Reviewer’s Initial Due Date Reviewer Reviewer’s Final Due Date APPLICATIONS WILL BE RETURNED/REJECTED FOR ANY OF THE FOLLOWING REASONS: It is the 1st application for a release at the site and DEQ’s eligibility determination letter is not attached to Part 1 of the application. Proof of payment of the appropriate deductible is not provided. The application addresses invoices for a prior period of time (Ex.: On 7/15/98, an applicant submits an application for 7/1/96 – 9/30/96 invoices, when an application for 10/1/97 – 12/31/97 invoices was previously submitted on 1/15/98). Note exception identified in B.1 below. A. SITE/OWNER INFORMATION (Site Name – Current Name) Name of Responsible Party as Identified in Part 2 - Affidavit (Site Street Address – Physical Address, Not P.O. Box) (DEQ Issued Owner Identification Number for Responsible Party) (City) (Parish) (DEQ Issued Facility Identification Number and Agency Interest No.) (No. of tanks owned in La. at time of incident by responsible party) FID: AIN: 1 –100 - $1 mil annual agg. 101 or more - $2 mil ann. agg B. APPLICATION INFORMATION 1. This application includes ALL INVOICES to the owner (responsible party) dated from: [Check appropriate quarter(s) and indicate year(s)]: July 1, ____through September 30, ____ October 1, _____through December 31, ____ January 1, _____through March 31, ____ April 1, ____through June 30, ____ The initial request for reimbursement will be accepted by the Trust Fund Section only after the site is deemed eligible and the deductible is met. Subsequent application requests must include all invoices dated during at least one calendar quarter: July through September, October through December, January through March, or Apri