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Underground Storage Tank Cleanup Fund vj <br /> r�� -. <br /> t : <br /> DETAILED REVIEW CHECKLIST <br /> IC181M NO.. <br /> -- 6�_ ClaEmani Mame ,P <br /> Fc �:� <br /> - alAnal �on. Pr' ISiteMame: �E <br /> DateRavIowetl/: _ ----tt3==lteAddro,a: �� <br /> Ctelm n Owner/O rotor T <br /> i <br /> Tax Eden en Provided I <br /> Joint Claimant Owner rator pt U$T t <br /> Tax tdantlficatlon Provided - -� <br /> I <br /> Financial Agreement Provtde_d_ <br /> Tax Identification Provided <br /> Tank Descr!ction,Tank Use <br /> Tank 3ubstanca _ ;I <br /> site arta Provided 2 A -- <br /> Ske Mat) <br /> Provf 0 rattst IdentHied - <br /> Date Site/Tanks A ulmd -- <br /> Acquired Atter 111184/F18asonabre pili ars E � '-7/7_._ ..- E r]t rir+cn <br /> Pest Owner/0 ratar Identified r`�"�c`� <br /> Other Claims For This Site Submitted - <br /> UnauthoNsed lease F <br /> Release Re rtod/Conf nrisd E3 ! <br /> -_ --Date Rel se Dlscove►ad Confirmed 4 - - <br /> CorrectlY6 Action Reguired_ - —_.__ __ ✓ <br /> Release Eli Ibte not a spill,pv-erfill sic 1 <br /> Carreadve Action - <br /> -. Release Prior to 1/1189,CA Initiated b 8/3 /98 i3 <br /> Corrective Action in Comcllene <br /> Permit ,- -• - <br /> Permit Re uiremertta Mat by 111/90 _• i <br /> Permit Waiver Being Requested - <br /> Permit Waiver Grented i ; <br /> ifinanaial Responsibility ��— <br /> �_Ctalmarn fn Comoiiance -- - _ ._._ 'i <br /> Lawsuk,Insurance Claim,Settlement 'r <br /> Date Pllad•Oate Complsted <br /> •_ Amount Received i <br /> Origins[$igndture a ;i <br /> Autnortucl Represantati><e <br /> I .loins Cwm-a t SiQnaturets� _ —•-- _ _.� <br /> USTCF025.DET(Rev.1/95) k <br /> I i <br /> 206 L99'ON CNnj 8f1NU3.10 isn 62:0T L6/b2/60 <br />