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s � Jai- f'•� +ti ��� ` ///�j//� � . <br /> i � <br /> r nderground. Storage Tank Cleanuwund " w <br /> n„.,._ f,ti _ iAREVIEW CHECK LIST <br /> DETAILED <br /> Claim No: L] Claimant Name: <br /> Region:- Prlorlty Assigned: Site Name: <br /> Date Reviewed::` Site Address�/,9 �� ' ZJ� f7p-EfT <br /> g <br /> Lead A enc!: <br /> r. <br /> Reviewe - <br /> 4iMA�C IDEYVTtF1CA.TMM Y tiERIFICATION 1V/l' YES.. No <br /> —”Clatmant"Owner/Operator of UST- <br /> Tax-Identification Provided <br /> :. fSTIMA'T .pFCOSTS,.a`. <br /> „'..SVERIFICAFION . WA:::..: YFS NO:..:. <br /> --Valid Thlyd Party Claim <br /> YERIRCATION <br /> _.. -__JoihtQWrnant_Owner/Operator..of.UST.-.__ _ .._.. _. _..____._..___.._.._......__ . _.__.. ..: _.. ..._. <br /> iiMupri Provided • <br /> :f <br /> :;.... :: V'ER 7dgT1ON ... N/A: YES. N.D';. <br /> _ ...:,. <br /> r :;:.Finaiidal Agreement Provided <br /> Tax lcenlrfic�tion Provided <br /> r1TEiRYl�4NK<3]F5CRIFION ... ...... A LMA.' a(ES <br /> ; dinK.1 sifto iif -ad-r&W llse <br /> - <br /> '�"` <br /> DalanksAcquired _-r- <br /> �,:fA P ( ie4d�erator,Tdeirttifierf' <br /> ,. p. <br /> �:Eorjh%s!$iterSubn}ftd <br /> jLlIIENa x VEIiIFICA77ON NlA' YES NOI <br /> . <br /> �� � .u� � as='..-6tte�►N61�d8: � - - -----------`��. __._._..--_�___...�- - - - - - - <br /> Tease.blsd <br /> .. -x•74: �. <br /> t stf�@'Ok n>.Requireclt s twir. i <br /> ; Reel�a`se�Eii"ible_ not a s ilE:averriil;`etc <br /> .Corr96&e.Action,:: is arta <br /> ,;Re)ease Prior_ gatedi'by 6/30/88 <br /> :-Coeikthie. ction n, ornpllance=:. <br /> r Permit Rerements Met by 1/1190 <br /> gw <br /> .Perrtnit•,Walver-Being Requested <br /> PermiL.Waiver Granted`: <br /> _ " : FinanclalResponslbiiity.., - 1 <br /> : Claimant in Compllance <br /> T�4TEMEIVTS':;.. 1/ <br /> FICA 7,70 .... NIA'; YES NO . <br /> Lawsuit, Insurance Claim, Settlement Af 110-n <br /> 4 Date Filed - Date Completed.. <br /> Amount Received <br /> , CER3"IF1CdT1ONS ' . .....' VERIFICATION. N/A: ':YES . NO <br /> Original Signature(s) <br /> Authorized Representative Statement X <br /> r Joint Claimant Signature(s) <br /> iUSTCF025.DET (Rev 1/95) <br />