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UNC tGROUND STORAGE TANK CLEANt/i"D <br /> COMWLIANCE REVIEW FORM <br /> CLAIM NO.: 13 S 1 CLAIMANT NAME: sQ 3-� W'1 T D r h 1 Q. &&S <br /> SITE NAME: I 114 1-7-kSITE ADDRESS: ,y L �1/ c"ti <br /> CLAIM PRIORITY: DEDUCTIBLE: S R, MULTIPLE CLAIM; #ot <br /> REGION: LEAD AGENCY: <br /> REVIEWER: Saha, DATE REVIEWED: <br /> TECHNICAL REVI"EW/PAYMENTS <br /> R LF SE CONFIRMATION DATE. Record the date the release was confirmed by the local agency—Uff <br /> FIRST DIRECTIVE. Record the date of the fust directive issued by the local agency/Regional Board: 5J d E-H-D I- (r )6—/?4/ <br /> GROSS NEGLIGENCE: Record any evidence of gross negligence found in the local agency/Regional Board file: <br /> INELIGIBLE COSTS. Record any evidence of ineligible costs related to this claim: <br /> CLOSE OUTS <br /> SITE CLOSURE: If site is closed,note date and get copy of closure letter for Close Outs Unit: <br /> SETTLEMENTS <br /> r <br /> OTWER FUNDS: Does evidence indicate that claimant has received tiulding from other sources? <br /> SETTLEMENT REVIEW: If so,has the appropriate documentation been reviewed by the Settlements Unit? <br /> .CLAIMS`RETjlEW <br /> CLAIMANT IDENTIFICATION <br /> ELIGIBILITY: Does evidence indicate that claimant owned and/or operated twik-(s)? 90 ��r m 17 <br /> JOINT CLAIMANT/CO-PAYEE <br /> ELIGIBILITY: Does evidence indicate that joint claimant is eligible to participate in the Fund? f 6 4F r er 111 i <br /> CO-PAYEEAGREEMENT: If a co-payee exist.-,has the co-payee ent been approved by the Settlements Unit? <br /> CONTAMINATEWSITE DESCRIPTION <br /> TANKISUBSTANCE- Does evidence indicate that tank/substance is eligible? S(7 I h <br /> USTCF025.COM(New 1 U97) ?age I <br />