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i <br /> I <br /> Underground Storage Tank Cleanup Fund <br /> DETAILED REVIEW CROCK LIST <br /> Claim No; f Claimant Name: 10 <br /> Region+ PAorlty Asaigned: fit, Site Now: p G 6 <br /> Date Revlawed: T/ $Its Addrea : A T > 7.., <br /> Reviewer: Lead AgencYi( .,..Y l.- ` Y <br /> CLAIMAlVT IDENTIFICATION �� . . VERMCATIONIOTA ' ' Y . . :7V.0 ,. <br /> Claimant OwnedOperator of UST <br /> Tax Identification Provided <br /> ESTIMATE OF costs <br /> VERIFICAT10N . . '. , Af/ , ': : , ''7YES <br /> Valid Third Partv Claim <br /> JOINT CLAIMANT VER/FI$ATIOIV ::. N 7 S <br /> Joint Claimant ownerlOperator of UST <br /> Tax Identification Pmvided <br /> C"AYEE YER/F ATIDN r: . CiNfA = : <br /> Financial A reement Provided <br /> Tax Identification Provided <br /> ,SITE HSTORWTANK DESCRIPTION WRIFICAIVON <br /> Tank Description, Tank Use <br /> Tank Substance ' <br /> SAO Map Provided <br /> Current OwnerlOperator identified <br /> Date Site/Tanks Atguired <br /> Acquired After 111164 Reasonable Diligencef'` <br /> Past owned0peralor Identified <br /> Other Cialms For This Site Submitted <br /> EUGL9II,.ITY REOUIREMENTS VERIFICATION WA : 'YES No <br /> Unaulhorbed Release f <br /> Releaso Reported/Confirmed r` <br /> Date Release Discovered Confirmed <br /> Corrective Action Required <br /> Release Eligible not a spill, overfill, etc <br /> Corrective Action <br /> Release Prior to 111106, CA Initiated by 6130166 <br /> Corrective Action in Compliance <br /> Permit <br /> Permit Requirements Met by 111160 <br /> Pemlit Waiver Being Requested <br /> Permit Waiver Grented <br /> Financlal Responsibility <br /> Claimant in Compliance ✓ <br /> STATEMENTS VERIMA20ION WA . YES NO <br /> Lawsuit, Insurance Claim, Settlement <br /> Dale Filed - Date Completed <br /> Amount Received <br /> CERTIFICATIONS VERIFICATION WA -YESNO <br /> original Si nsture(s) <br /> Autttoriced Representative Statement <br /> joint Claimant Si natures) <br /> USTCF025.DET (Rev 1195) <br /> cPfJ 9L0MUN 8£10b9bbL2. L6 «- sten dn[41J nM lsn R : £1 Lb/LT/L0 <br />