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JAW03-1996 13:07 UST CLEANUP FUND 916 227 4530 P.02iO4 <br /> Underground Storage Tank Cleanup Fund <br /> DETAILEn REVIEW CHECK LIST <br /> Claim NO: /O pQ Claimant Nam <br /> ftsgion: ! <br /> Priority Assigned; `2i Site Mame: <br /> Revi <br /> Date ewsd: / , 7 rp •L� Site Address: <br /> Reviewer. Lead Agency: <br /> 41 <br /> CIAJMANT2OE11iTIF(Clff7Oilt:a . .. . <br /> Claimant OwnedOperatoT of UST <br /> Tax Identitication Provided <br /> 111=h119[CA I 'WA.: YES WO <br /> Valid Third Party Claim . <br /> . . ::,r : :?VE.RfFICA7iON ..::.: .:.:M!A : -YES. .• .1'l� <br /> _aO/�[FGIci4I111ANT. . <br /> Joint Claimant Ownedoperator of UST <br /> Tax Idsnlificalion Provided Y <br /> -. -. ...YER/F!,CA'F �:1::. .._. M/A : ...YES:: .NO!: <br /> E4PAYEE <br /> Financial Agreement Provided <br /> Tax Identification Provided <br /> S/ `HISTORY1rANKDESCRtf�(OM ?YERtFf6ATlUb.:', WA. YES NO. <br /> Tank Description. Tank Use <br /> Tank Substance <br /> Site Map Provided <br /> Current Owner/Operator Identified <br /> Date Siterfanks Aoquired <br /> Acquired After 111184 Reasonable Diligence <br /> Past Owner/Operalur Identified <br /> Other Claims For This Site Submitted <br /> N/A YES i'JO.: ... <br /> Unauthorized Release <br /> Release Reporledr-onfirred <br /> Dale Release Discovered Confirmed <br /> Corrective Action Required <br /> Release Eli ible not a s ill, overFll, etc <br /> Corrective Action <br /> Release Prior to 111188. CA Initiated by 6130188 <br /> Corrective Action in Compliance <br /> Permi[ <br /> Permit Requirements Met by 1/1/80 <br /> Permit Waiver Being Requested <br /> Permit yuahrer Granted <br /> Financial Responsibility <br /> Claimant in Compliance <br /> 'S7JffEMEK;TS.i� ••"tiERIFl�Ai`YRN :' A ' '=''YES tvO'. <br /> Lawsuit. Insurance Claim,3etdement <br /> Date Filed -Date Completed <br /> Amount Received <br /> . ..7rSCA1TON <br /> --7-77-777777= <br /> .. ... <br /> Original Signature(s) <br /> Authorized Representative Statement <br /> Joint Claimant Signature(s) <br /> USTCF025DET(Rev 1195) <br />