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UN--%GROUNI�k$TORAGE TANK CLEANU vD ' <br /> h4� CONIPEIANCE 'V �'4�,T $ .-A-, <br /> REIE <br /> •CLAIMANT NAME. 5311 <br /> NO , <br /> 1 1 STFE ADDRESS. d <br /> F: SITENAIVIE. ;DEDUCi'IBLE• 'i a MULTIPLE CLAIM <br /> ' CLAM PRIORM. ' ' ., <br /> yw �: AGENCY <br /> REGION LE" s <br /> DATE REVIEWED <br /> ;� REVIEWER. <br /> f:. <br /> Y <br /> RELF.ASE.CO.NR MATIONDATE Record the date the release was confirmed by the local agency " <br /> •gig, <br /> FIRST.DIRECTIVE: Record the date of the fust directive issued by the local agencylRegionai Board <br /> ? GROSS NEGLIGENCE: Record any erndence of gross negligence found in the local agency/Regi 61 Board file: <br /> i i <br /> INELIGIBLE COSTS:'Record anY evidence of-ineligible costs related to this claim: _ .. <br /> ti777 <br /> CLOSE OM <br /> :'. <br /> S1TE•CLOSURE:=If site is closed.,note date and get copy of closure letter for Close Outs[Jmt' <br /> SETTLEMENTS' 17L ,... <br /> a .OTHER FUNDS:"Does evidence.indicate that claimant has received.fiuiding from other sources? <br /> 1 SET7ZEMENT REVIEW. If so,has the appropriate documentation been reviewed by the Settlements LTmi? <br /> t f� <br /> 4 <br /> IMPS. <br /> M. <br /> I ELIGIBILITY: Does evidence indicate that claimant owned and/or operated tanl:(s)? ? _ <br /> i <br /> Y �;. ELIGIBILITY: Does evidence indicate that joint claimant is eligible to participate in the�Fund?, <br /> .a._- <br /> C0.PAYEEAGREEMENT` if a co-payee exists ie co-payee agreement been approved by the Settlements Unit? { <br /> (( M <br /> i ... - <br /> 1 iP � <br /> } GONTAiVYINA'TED.SITE;DESGR1PTiON .:, .,. : :.' .. `... . :.`.: <br /> TANK/SUBSTANCE: Does evidence indicate that tmW-substance is eligible? 1 <br /> Page <br /> USTCF025.COM(New I V97). L <br /> ') <br />