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..._.j <br /> Underground Storage Tank. Cleanup Fund <br /> DETAILED REVIEW CHECK UST <br /> e: <br /> ' Claim No: Claimant Nara <br /> •�- <br /> Region: Priority Assigned: Site Baena: <br /> Data Reviswed: Site Address: <br /> Reviewer. Load Agency: <br /> r <br /> ... - ...♦: v .rr...H.-:...:.'..i:."t..:: .r.-.: tel.' ' .. .. �- <br /> Claimant OwnedOpsrator of UST r <br /> Tax Identification Provided <br /> A. <br /> Valid Third PaM Claim <br /> ;:: :1r lYT :c:. .,•...:....... . ......:' "�FIG`i4�t�IVlr i ':� :•>:.: .�9:: <br /> Joint Claimant Ovow/O r8tor of UaT <br /> Tax Identification Provided �. <br /> zi �.�i�-.: .RliFI+IhA .�tCi 1#;:.:;: w��:�.. •;".fl%t •: �. <br /> Financial A mement Provided <br /> Tax Identification Provided <br /> Tank DescAption, Tank Use <br /> Tank Substance <br /> Site Map Provided � <br /> Curerd OwnerlOpereter Identified ✓ <br /> Date SItelTanks Acquired <br /> Acquired Alter 111/84 Reasonable Diligence <br /> Past Own rotor Identified <br /> Other Cialms For This Site Submitted <br /> v • .. , :�I .. .Ltx ...:....: : : .. -:_ :::fid•.;: ;:;::5r�u::: .::l+l'O . <br /> Unauthorized Ralseee <br /> Release Reported/Confirmed <br /> Date Reia se Discovered Confirmed <br /> Corrective Action R Ired ✓ <br /> Reteeoe Eligible not a e iD, overfill, etc <br /> Corrective Action <br /> Release Prior to 1111188, CA Initiated by Sa0188 ,, 111 „, „�? 4,0 r.r <br /> Coffeallve Action In Compliance <br /> Permit <br /> Permit Requirements Met by 111194 Y <br /> Permit Waiver Being Requested <br /> Permit Waiver Granted <br /> Financial Responsibility r <br /> Claimllint In Compliance ,f` <br /> Lnwsuil, Incumnec Claim, Settlement <br /> Date Filed-Date Completed <br /> Amount Received <br /> ,, .. .Tr<;, �YYDN . .;.,,•''.': F :TfiD?Y: • <titiM'�'s:� .���t+C <br /> final Mature s <br /> Auilwnzed Re resentatiue Statement <br /> JNnt Claimant S' eWm(s) <br /> USTCF02S.DET(Rev 11135) <br /> 110d 6LL^t3N 62T0V9V60ZT6 { UN,9A dnNU3-0 ISI-1 02=TT L6190190 <br />