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�r..ar w�mvr�r rVIVL a �1CG7404G13YJ NO.777 P02 { <br /> Underground Storage Tank Cleanup Fund <br /> DETAILED REVIEW CHECK LIST <br /> Clslm No: O / <br /> f CIalnrant Name: <br /> Region: f Prl myAssigned: <br /> „} Sita Name: / <br /> Date Reviewed: <br /> a a.3 94, atte address: <br /> Reviewer. Lead Agsnry: <br /> ::'t�''LA1Ma{j�tf-1tJ A13i <br /> Ural ant Ow "1✓ flRCA1T0 <br /> nanl?perator of U57 <br /> Tax Idantlflcation Provided "' d <br /> MAMA rE <br /> vaiid 'fhiroPa Claim <br /> J Joint CJ.airna--T. erlOperatar of U <br /> Joint Claimant Own TIRlAT/ON :; <br /> ST <br /> Tax Identification Provided <br /> Financial mens Provided ., . 'VERI7TGAXipN.r.::. <br /> Tax ldentiftcation Provfdad <br /> Six [tJ§rtfifRz N 'or— Tpnt: <br /> Tank Descri n, Tank Use : .:._ > rS 1JERlFfC�g11O'pr <br /> .Tank Substance I <br /> Silo Me Provided <br /> Current OwnerfOpetator idenfified <br /> Data Site7Tanks iced <br /> Acquired After 1/11114 Reasonable Diligence <br /> Past Owner/Operstor Identated <br /> Other Claims For Tt17s Site Submitted <br /> l:G AB rY' E4t17Rt�(I�N1S I� <br /> UnauthoNzed Raloose ..� <br /> adarrred . ..,c 'a rirXE3 <br /> Release R... <br /> Date Release Dlswvered Calltrmad F <br /> Corrective Action R uired <br /> Release F) Ibis not a s ill, oveMill elc <br /> Corrective Action <br /> Release Prior to 1/1188. CA initiated by 8!30/88 ! <br /> Corrective Action in Com pence <br /> Permit € <br /> l <br /> Permit Requirements Met by 111190 <br /> Permit Waiver Being Requested . <br /> Permit Waiver Granted <br /> Financial Resporrsibllity <br /> Claimant in Compliance <br /> t.eweudr Insurance Claim, Settlement <br /> Data Filed Date Compteted <br /> Amount Received � <br /> 0 at S' natures ,':t2R1�7CA71r <br /> Authorized R <br /> epresentafive Statement <br /> Joint Claimant Si lure s) i <br /> USTCF025.DET (Rev 1785} <br /> 4 ( <br /> i <br /> i <br />' J <br />