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Underground Storage rank Cleanup Fund <br /> DETAILED REVIEW CHECKLIST <br /> Claim No.:d Claintw Name: 1;qAM.44*=6e 51 <br /> j <br /> Region: j- 1Prior1ty Awtgned Site Neme _ y [�E �� <br /> -'— --- . <br /> IbDat■—Rw-kwed /-i - Z— sne aedr.ta: 3.76- zcl 7p - <br /> Claimant Owner/Oporator Of UST_. <br /> z. Tax Identification Provided <br /> Ve114 Tnirtl Party Claim -- _-- - i <br /> Joint Claimant Owner/operator of <br /> Tex identification Provided -- - 1--- <br /> Financial Agreement Provided .. ..•.- --- -. <br /> Tax IdentBlcetlon <br /> wood _ <br /> Tank DesedOtlon.Tank Use -- <br /> - Tank Substance --- <br /> Site Mep Provides - <br /> Current Owner rator ldentlflecf-_ _... -,-- <br /> Date SlteRanks Ac- red -__ ._ - - .--- ✓ <br /> Acquired Atter 1/1/94/RBasgnagte 0itigerl .............._ - ✓ <br /> Past er/ rator identlllad - i --- <br /> Other Claims For This Site Submitted - --- <br /> UnsuMods�Mlewe ,/ <br /> Release Ra oned/ ontinned -'- <br /> _. Date Release Discovered Confimgd- ___._ _.... - ✓ <br /> Release Offilble inota 'tl overfill,etc --• _ <br /> CorMolve A n <br /> Release Prior to 1/1/SS,CA Inflated --- <br /> Corrective Action In Com Ilanca <br /> P�tmlt <br /> ._Permit Requirements Met by 1/1/90 <br /> Permit Waiver Solna Requested <br /> Permit Waiver Granted <br /> (Financial RNiw!talbll ✓I I <br /> Claimant in Gompkance <br /> Lawsuit,Insurance Claim.Settlement <br /> l __.Dote filed-Date COmpleterf .-- <br /> Amount Received - - - -' <br /> - <br /> AutnodzedRegresentethreStetem <br /> _joint Claimant Signaturs(s1 <br /> USTCF02S.DET(Rev.1/95) <br /> 226 290-DN QNn3 dnNd310 19ft 0T:2T L6/DT/TT <br />