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Underground Storage Tank Cleanup Fund <br /> DETAILED REVIEW CHECKLIST I "1 <br /> �� <br /> ClafmNo.: � CleFinantNmne: svrV 6 A ?!p - - - - t� 1' <br /> Ae Ion Prior i ned• _ U _' I <br /> i. ilY * . __ Stte Nema• 61 fz__ _ _ __ _ _- _ _ <br /> Dstg Revrawed: - Site Address_ <br /> LesdAwncill <br /> Tax Identiffcatiun PraWded._ <br /> Valld Third Party Clalm <br /> i Joint Caiman Own r! erator of UST-"-_ <br /> Tax Identlffcatfan Provided . .. ..,.�..... . ..... . ........... . : .. . <br /> Fnand I reamant Provided_... ......._ .__,-_,_._.__•_,.•.,_,_ _,.., ._-- <br /> Tax Identification Provided <br /> Tank Descrption, Tank Use <br /> Tank Subrstance <br /> $@e Map Provided ,....._.—_ <br /> Current OwnerlOperatur idGmilled ✓� <br /> Date Sita/Tanks A Wed <br /> Ac red After iM S4111sasonable OUI enc _ •` _ <br /> Past Owner/Operator tdentifiad <br /> Cla(•arla.F r to 9ke 3ubrttlUetl •� -"`"___. � - � ; <br /> Unauthorized Relaw <br /> _ Release ReoodedrConfirmad <br /> Date Release Discovered Confirmed <br /> Corrective Action <br /> Relgeae Elt ble nota tl overlill,,,e <br /> Cermadwo Aetitm <br /> Release Prior to 111188 CA Initiated by W31 VM <br /> CorrMlvD Action in Com liana ,... - <br /> PerrNt i <br /> Permit Requirements Mel by, 111/80�„ <br /> Pwmlt Waiver agingRfAuestad <br /> Permit Waiver Granted _ <br /> Flnanckl Rasillansibillity <br /> Claim Ln <br /> Lawsuit. Insurance Claim. Settlement i <br /> Date Flletl • Data ConlTeeled <br /> ''AmOunt R9Ceived ' __ , <br /> FIN <br /> Original Slenaturefs) <br /> Aulbodred Re rgsentativa Sletemem <br /> Joint Claimant Signature --- <br /> USTCF02S.DET (ileo. 11811) <br /> OTd 6LL 'ON B£T0b9b6OFT6 F ❑Nfld dnNU3-l? 1Sft S£ : TT 246150/50 <br />