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Underground Storage Tanis Cleanup Fund <br /> DETAILED REVIEW CHECKLIST <br /> —� Claimant N&M: <br /> Claim No_ _. .:.. <br /> �Priority AssiRnW• Sits Name_ -$4CT2 -- <br /> Date Pavia!"& - � Site Addr_esa:__.�L <br /> I --- C - ----�—. 1/�lAa",44 <br /> f <br /> I ._-....._toylyum: lead <br /> Claimant own tor of LIST <br /> j�Tax Identiftcat.on Provided _ _._._r .- _.. ----- rEll - <br /> +a <br /> i <br /> !I valid Tnird Pan Claim ---- - <br /> 4 <br /> il <br /> Joint Cislmant OwnerlOverator of UST..,__ ii l <br /> I <br /> Tax Identification Provided <br /> Finartelst A rsemenl Provided —_.•,_ __-..,.-.-. - <br /> Tax identification Pmvldedr.._.__ <br /> !I Tank pesefl on Tank Use <br /> Tank Substance <br /> Site Mjapfrowded <br /> Currant Ownapp razor Identified ____r <br /> vel <br /> Date <br /> ulSed@A Itflanks ACQulred -_ --._ ........_ <br /> —qtter 14164fflamnable Diligen" <br /> Paat Owner/Operator Identified --- <br /> Othar Claims For This SRO Submhted <br /> Unauthorized Relsess <br /> Release Re rNvYQ Mirmsd <br /> Date Release Discovered Confirmed <br /> __ Corrective Aalton Required _...._._..,-._. <br /> Release Eligible inot a 901,overfill,etc}-• r _-__._ d <br /> Correcthro Adtlon <br /> - Release Prior to lli1f3f3 CA Initiated b _- Q _.__.._.._. --- <br /> _ Corrective Atxl4n in Com flans __ �_ --_.--.- <br /> Permh - ✓ i <br />' Permit R irements Met by <br /> Permit Waiver going Requested <br /> Permit Waiver Granted _.._ <br /> rFinsncisl Responsibility ` <br /> iI Claimant in Compliance <br /> !I <br /> Lawsuit,Insurance CIAIm,Settlement <br /> Qxg t=iled•pats Cam lined <br /> _AmountReceived ___.._. . <br /> Ori incl Si na ' <br /> furs sL_ ' <br /> I <br /> Auttwr'zed Representative Statement _ - 7 i <br /> loin!Claimant Signeture�s�_ <br /> USTCF025.DET(Rev. 1195) - <br /> Ir- Mel 1220•on, CINn� dnNU3 Asn r.� 60 7 L6�21�ZT <br />