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Underground Storage Tank Cleanup Fund <br /> DETAILED REVIEW CHECK LIST <br /> Cm No: 7 Clalmant Nama: <br /> Reglan: Priority Assigned: Site Name: �4 <br /> Date Reviewed: /Y SLI ' ;�'/ Ska Address C - <br /> Reviewer: iJ U h , . ..� Lead Agency: <br /> CLAIMANT IDENTIFICATION IG`At7ON 6 N/A YES, lid <br /> Claimant owner/Operator of UST <br /> Tex identification Provided <br /> ESTIMATE OR COSTS VERIFICATION W - YES; NO <br /> Valid Third Pa Claim <br /> JOINT CLAIMANT tAFRJFICATION -WA YES NO <br /> Joint Claimant Owner/O rator of UST <br /> Tax Identification Provided <br /> CO•PIAYEE _VERIFICATION WA I YMS ND-- <br /> Financial Agreement Provided <br /> Tax Identification Provided <br /> SITE HISTORMANK DESCRIPTION VERNIOATION WA , iM NO <br /> Tank Description, Tank Use <br /> Tank Substance �✓ <br /> Site Map Provided <br /> Current Owner/Operator Identified <br /> Data Sitefranks Acquired <br /> Acquired After 111184 Reasonable Diligence <br /> Past Owner/D erstor Identified ✓ <br /> Other Claims For This Site Submitted ✓ <br /> ELRiI91LITYREQIIIREMENTS VERIFICATION WA YES NO <br /> Unauthorized Release <br /> Release ReportedlConfirmed <br /> Date Release Discovered Confirmed <br /> Corrective Action Required <br /> Release Eligible not a spill. overfill etc <br /> Corrective Action <br /> Release Prior to 111188, CA Initiated by 8/3088 ✓ <br /> Corrective Acton in Compliance <br /> Permit <br /> Permit Requirements Met by 1/1190 �v <br /> Permit Waiver Being Requested <br /> Permit Waiver Granted <br /> Financial Responsibility <br /> Claimant in Compliance <br /> STATEMENTS VERIFICATION IMA"' JYESN!40 <br /> O` <br /> Lawsuit, Insurance Claim, Settlement <br /> Date Filed - Date Completed <br /> Amount Received <br /> CERTIFICAT/ONS VERIFICATION N/A <br /> Original SI nature$ <br /> Autnonzed Representative Statement <br /> Joint Claimant Signature(s) <br /> USTCF025.DET (Rev 1195) <br /> 200 £26'ON QNN-,i anNd37S 1Sn 2£:0Z L6i82i0Z <br />