Laserfiche WebLink
rf <br /> Underground Storage Tank Cleanup Fund <br /> i DETAILED REVIEW CHECK LIST <br /> Claim Na: � C— Claimant Name: <br /> Region: Priority Assigned: Site Name: <br /> 3 <br /> Date Reviewed: Ll 9Site Address: <br /> /0 <br /> Reviewer: Lead Agency: ` /O <br /> CLAIMANT IDENTIFICATION • VERIFICATION N/A YES NO <br /> Claimant Owner/Operator of UST �( <br /> Tax Identification Provided <br /> ESTIMATE OF COSTS VERIFICATION N/A YES NO <br /> Valid Third Party Claim <br /> JOINT CLAIMANT VERIFICATION N/A . YES NO <br /> Joint Claimant Owner/Operator of UST <br /> Tax Identification Provided <br /> CO-PAYEE VERIFICATION /A YES NO <br /> Financial Agreement Provided <br /> Tax Identification Provided <br /> SITE HISTORY7TANK DESCRIPTION VERIFICATION N/A YES NO <br /> Tank Description. Tank Use <br /> Tank Substance <br /> Site Map Provided <br /> Current Owner/Operator Identified <br /> Date SitelTanks Acquired N& <br /> Acquired After 1/1/84 Reasonable Diligence <br /> Past Owner/Operator Identified <br /> Other Claims For This Site Submitted �( <br /> ELIGIBILITY REQUIREMENTS VERIFICATION N/A YES NO <br /> Unauthorized Release <br /> Release Reported/Confirmed V <br /> Date Release Discovered Confirmed <br /> Corrective Action Required <br /> Release Eligible (not a spill, overfill, etc <br /> Corrective Action <br /> Release Prior to 1/1188, CA Initiated by 8130/88 <br /> r <br /> Corrective Action in Compliance <br /> Permit s <br /> Permit Requirements Met by 1/1190 <br /> Permit Waiver Being Requested y <br /> Permit Waiver Granted <br /> Financial Responsibility <br /> Claimant in Compliance <br /> STATEMENTS VERIFICATION N/A YES NO <br /> Lawsuit, Insurance Claim, Settlement �P <br /> Date Filed - Date Completed <br /> Amount Received <br /> CERTIFICATIONS VERIFICATION N/A YES NO <br /> Original Signature(s) <br /> Authorized Representative Statement f <br /> Joint Claimant Signature(s) X <br /> USTCF025.DET (Rev 1195) f <br />