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Underground Storage Tank Cleanup Fund ; <br /> DETAILED REVIEW CHECKLIST <br /> Claim .: ClalmantName- /�"D&__�n7f <br /> Ie lon.�Priori_ Assigned. <br /> _ Site Nome: <br /> �[Data Reviewed: 9 ____Site Address. ... Y <br /> —• A <br /> 'SPAT. <br /> La d A <br /> Claimant Owner/Operator of UST,_ <br /> i Tax identification Provided__ <br /> �Vall4 Third Party Claim .... . __ ..—_ —_.. _ _..._ ___.— .: ....... <br /> "Joint Claimant Owner/Operator of UST <br /> Tax Identification Provided <br /> Financial Agreement Provided <br /> Tax Identification Provided <br /> Tank Description,Tank Use <br /> Tank Substance _. __. — ✓ <br /> Site Map Provided _--- <br /> Current Owner/Operator Identified <br /> _Date Site/Tanks Acquired <br /> Acquired Aftery1/84/Fteasoneble DiG enc <br /> ----- - <br /> ^PaatOwner/Operatorldentified ------ <br /> Other Claims For This Site Submitted i ✓- <br /> Unautharised Rolease <br /> _Release Reported/Confirmed _ _ ✓ <br /> Date Release Discovered Confirmed ___._._. ✓ _Y <br /> Cgrrective Action Required <br /> Release Eligible not a s 'II,overfill,ate) w... <br /> Corrective Action <br /> Release Prior to 1/1/88,CA Initiated by 6/3 188 <br /> Corrective Action in Com lance <br /> Parirtlt Ii <br /> Permit Requirements Met P-30.0/90 <br /> Permit Waiver Being Reguestatl <br /> Permit Waiver Granted <br /> �FInancial Responsibility 1 �' <br /> Claimant in Compliance <br /> t_awsult.insurance Claim,Settlement <br /> Hata Flled-Date Completed <br /> Amount Received <br /> Oncinal Siansture(s) ✓' <br /> Authorized Representative Statement <br /> Jo►ntClalmant SignatureLzI... ._.. <br /> USTCF025.DET(Rev.1/95) <br /> 226 22:9'ON QN(1-:i d()NU310 1Sf) ®b=GT L6/GT/60 <br />