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kww� <br /> Underground Sloragg Tank Cleanup Fund <br /> DETAILED REVIEW CHECKLIST <br /> ..claimantHama: <br /> 9!�It <br /> Sit®Name: <br /> jp2!8RGvlw&d.- -IOU - Y'7 Site Addross: <br /> Lead AganpVt <br /> UST <br /> Identification Provided <br /> F ... .... <br /> Valid Third Party Claim <br /> Joint Clownant OwnerlOperatar of UST <br /> Tax iftntification Provided <br /> Firanalal Acirsament Provided <br /> _Tax Identification Provided <br /> Tank 3qqcjfp1fon.Tank Uae <br /> Tank SubMnce <br /> Site MRp PmAded <br /> Current 04mlLQ29mvK Identified ✓ <br /> Data SitatTarks Acaulred <br /> Acguired After 1/1/84/Rpasqnakfq_MA1qnqg <br /> Fast Ownor/Opprator Identified <br /> Other Clairm For TbIs SE o S&rrfiftad <br /> Reims*Ftvpo!Lcd/ConfbTnqq.._... <br /> Date Rel ea Disemwed Confirmed <br /> Corrective Action Rectulmd <br /> Release Ellalble(not a sold,PiLairfill.9-t-M.- <br /> Corrocdvo Action I <br /> Hefease Prior to 111188,CA Initiated by 99 <br /> Cormclive Action in Com Dilarce <br /> pemit <br /> Per rnft Requirements Katt <br /> Parmit Waiver Soft Reg vested <br /> Permit Waiver Granted <br /> LFI,nanclnl R=_pqn0lb1l1!x I <br /> Claimant in Cpm[?Rnca <br /> Lawsuit,Insurance Claim,Setttpment <br /> Date Red-Date Com feted ....... <br /> Amount Rocelved <br /> *j 4�1 t. <br /> .-Orlignal Siginviure(s) <br /> Aj!tho►ged R rexqqtntivq Statement <br /> Joint claimant Sigraitum(§) <br /> USTCF025.DET(Rev. 1126) <br /> 9217"ON <- aNnd dnN1J3­1Disn 6Z:60 86/80/T0 <br />