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I` Agencg Information i.eax�ng underground Fuel Storage Tank Program gate. <br /> A �� <br /> Agency name: Address: <br /> City/State/Zip: I Phone: I ` <br /> I. Responsible staff person: Title: i <br /> II. Case Information I # <br /> I <br /> Site facility name: <br /> Site facility address: <br /> RB LUSTIS Case No: Local Case No: I LOP Case No: <br /> URF filling date: SWEEPS No: <br /> Responsible Parties Addresses i Phone Numbers <br /> I <br /> I� <br /> Tank No Size in Gal. Contents Closed in-Place/Removed? Date <br /> 1 <br /> 2 <br /> 3 <br /> III. Release and Site Characterization Information I� <br /> Cause and type of release: <br /> Site characterization complete? Yes No Date approved by oversight agency: <br /> Monitoring Wells Installed? Yes No Number: Proper screed interval? Yes No <br /> Highest GW depth below ground surface: Lowest <br /> ;,.depth: Flaw direction: <br /> Most Sensitive Current Use: i <br /> Are drinking water wells affected? Yes No Aquifer name: <br /> Is surface water affected? Yes No Nearest/affected SW name: <br /> F <br /> Off-site beneficial use impacts (addresses/locations),: <br /> Report(s) on file? Yes Nowhere is report(s) filed? <br /> Treatment and Disposal of Affected Material <br /> Material Amt. (inc. Units) Action (Treatment or Disposal w/Destination Date <br /> Tank <br /> Piping Ij <br /> Free Product <br /> Sail <br /> Groundwater � . <br /> Barrels �. <br /> Exhibit N Page 1 of 2 <br />