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Underground Storage Tank Cleanup Fund <br /> DETAILED REVIEW CHECKLIST <br /> rt/ y �AA07 <br /> C!1'�M7_14o.; 10 7-Y/ Claimant Narns:_ <br /> ,Pr1qr11yAss1gnsd: - _ 6 <br /> In6plon: .5 A Y, <br /> Date Reviewed: /1�_7- Site Address:'qz- <br /> eviwwr. a <br /> —Lead Ag ncy <br /> Claimant Owner/Operator of UST <br /> 7 <br /> Tay Identification Provided—_ <br /> Valid Third Party glairn <br /> Joint ClAlMani Owner/Coerstor of UST ------ ------ <br /> Tax identification Provided <br /> - <br /> MAFinancialAgraeopent Provided <br /> ._T"Identification Provided <br /> Tank Description,Tank Use <br /> Tank Substance <br /> Site Map Provided <br /> Current Owner/Operator Identif led <br /> Date Site ranks Acquired <br /> Acquired After 1/1/84/Reasonable DUO-M.— <br /> Past Owner/Operator Identified <br /> L Other Claims For This Site Submitted <br /> Unauthorized Release <br /> Release 9�"dtContlrmsd <br /> Date Release Discovered Confirmed <br /> Corrective Action Required <br /> Release Eligible not a so <br /> .(1,9verfill.etc) <br /> C <br /> orrWive Action <br /> -Balt"k-Erfor to 1/1/0$.CA initiated b 6408 <br /> Corrective Action in Compliance <br /> Permit <br /> Permit Requirements Mot Dy 111/98 <br /> Permit Welver Being Requested <br /> Permit Waiver G?ant*d <br /> Ifinanclel R"pq Ity <br /> Claimant In COTPRIncilt- <br /> lawsuit,Insurance Claim,Settlement <br /> Date Filed-P&WC feted Amplatea <br /> Amount RPcO1ved <br /> I OrigInal Sjg!ja�urG(!j_ <br /> AUthorlZed Representative Statement <br /> Joint Claimant SI natures <br /> USTCF02B.DET(Rev. 1/95) <br /> 71201 PCT *nN iNnA iqn Pr-:PT 1.F,/TA/?T <br />