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I <br /> Underground Storage Tank Cleanup Fund a <br /> DETAILED REVIEW CHECK LIST <br /> [Claim No: D/Q Claimant Name: { <br /> Region: Priority Assigned: �j Site Name: <br /> Date Reviewed: Site Address: r f <br /> Reviewer: Lead Agency: ` Ji <br /> Cl:AIMANT.IDENTIFICATION RlF1CATION <br /> Claimant Owner/Operator of UST <br /> Tax Identification Provided �Vr3 ?� � <br /> vF <br /> ESTIMA'TE.0F;(COST5 <br /> RIFlCA770N .... ! N/A.. YES.:.. <br /> Valid,Third Party Claim ,�. ,• .� �-�.* - - LL. , �.; <br /> ;l0lNT:CLAIMANT ;; <br /> VERIFICA'TlDN <br /> Joint Claimant Owner/Operator of UST <br /> Tax Identification Provided <br /> D-PAYEE <br /> I E"CA TION <br /> NIA::: <br /> YES' NQ, <br /> Financial Agreement Provided <br /> Tax Identification Provided <br /> SITF NISTo13Y%TAIVK;DESORIPIlON VERIFICA710N N/A..: YES N ` <br /> Tank Description, Tank Use <br /> Tank Substance <br /> Site Map Provided <br /> Current Owner/Operator Identified ✓ <br /> Date Site/Tanks Acquired / D /u <br /> Acquired After 1/1!84 Reasonable Diligence <br /> Past Owner/Operator Identified ✓ <br /> Other Claims For This Site Submitted <br /> EGIGlBlL1TY..REQUIREMENi`S;'. " 1/ERIFIGATION, N/A >. ..YES NO <br /> Unauthorized Release <br /> Release Reported/Confirmed <br /> Date Release Discovered Confirmed <br /> Corrective Action Required ✓ <br /> Release Eligible not a spill, overfill, etc <br /> Corrective Action <br /> Release Prior to 1/1/88, CA initiated by 6/30188 <br /> E Corrective Action in Compliance <br /> Permit - <br /> r Permit Requirements Met by 1/1190 <br /> Permit Waiver Being Requested <br /> Permit Waiver Granted <br /> Financial Responsibility - µ <br /> Claimant in Compliance <br /> ST,4TEMENTS ;'. VERIFICATION ,. YE5 NO <br /> N/A <br /> Lawsuit, Insurance Claim, Settlement - <br /> Date Filed - Date Completed <br /> Amount Received <br /> :CERFIFICAFIONS <br /> . . <br /> YER]FICA'TlON N/A YES NO <br /> _Original Signature(s) t - . :."". :M,.. ✓ <br /> Authorized Representative Statement ✓ - <br /> Joint Claimant Signature(s) <br /> USTCF025.DET (Rev 1195) <br />