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Underground Storage,Tank Cleanup Fund <br /> DETAILED REVIEW CHECKLIST <br /> �— CieimOnt Nail <br /> Cla1. <br /> ire NaIt .. ———- — — <br /> _....s)te Name: <br /> Reglonq. lF!rlori_ ,�s, a_ ._.._ ,Lr t/ l �- <br /> ✓ l I <br /> Ctslmant Ow�ter(O >atur of UST <br /> n Provided <br /> _ Tax ldentiPloatio <br /> valfd Third"Parh+,Glaim — <br /> Jgint Claims <br /> -- <br /> Tax Identification Provided <br /> Financial reement Provided—... <br /> Tax identRication Provided <br /> Tank D tion Tank lase <br /> Tank Substance <br /> Site M Provlded -- --� f <br /> Current owner! arator Ident led-• Y ,/ <br /> Date Site/Tank—AtIrkidnW1 - --� <br /> A ulaci rad Atter y11/BMl�sas stsls D1li en r— -- <br /> Pas C�vvnerto Orator Identifled <br /> other Claims For Thla t Subm+tted <br /> Uneutharixed ReIowa <br /> Relaaee�, ROcddedlGbn ad �'� <br /> Da O Release Discovered Confirmed f <br /> Cortedi Actlon Ra iulrsd„ ., - <br /> f?etaasg Ell Ibfe not a R0111.ave rfllf,etc) _--�--•• �—° <br /> Cor*eetive Aotion j <br /> Release Prior to 111!88,GA Inwaj b t3! <br /> Corrective ction M Comm !lance •,__. -- —�� <br /> Permit Yk �/ I <br /> PermR 39guiramente Mat bV i/V90 <br /> Psrrnit Waiver Saln F -tad - -- <br /> Permit <br /> `nnianclai_ I��pQnsiblii <br /> Cfaimpnt in Comoliartce " - <br /> Lawsuit.Insuranrae Claim,Settlement _�.--- �----? <br /> I Ds a Flied-,Date COMP191e0 <br /> Arnyunt Racsiwd .. _..�—, -- - <br /> Authorized Re re9enlaw"Statement <br /> �,_Aloint C:taimOnt Si natures .—. ... .- - •- <br /> USTCF025.DET(Rev.1196) <br /> 200 806'ON 8ET0179060ZT6 F QNlld dnNU31O 1Sfl SF-:ST 2,6/PZ/90 <br />