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Case Closure Summary <br /> Leaking Underground Fuel Storage Tank Program <br /> I Agency Information Date: <br /> Agency name: Address: <br /> City/State/Zip: Phone: <br /> Responsible staff person: Title: <br /> II. Case Information <br /> Site facility name: <br /> Site facility address: <br /> RB LUSTIS Case No: Local Case No: LOP Case No: <br /> URF filing date: SWEEPS No: <br /> Responsible Parties Addresses Phone Numbers <br /> Tank No Size in Gal. Contents Closed in-Place/Removed? Date <br /> 1 <br /> 2 <br /> 3 T_ <br /> III. Release and Site Characterization Information <br /> Cause and type of release: <br /> Site characterization complete? Yes No Date approved by oversight agency: <br /> Monitoring Wells Installed? You No Number: Proper screen interval? Yes No <br /> Highest GW depth below ground surface: Lowest depth: Flow direction: <br /> Most Sensitive Current Use: <br /> Are drinking water wells affected? Yes No Aquifer name: <br /> Is surface water affected? Yes No Nearest/affected SN name: <br /> off-site beneficial use impacts (addresses/locations) : <br /> Report(s) on file? Yes No where is report(s) filed? <br /> Treatment and Disposal of Affected Material <br /> Material Amt. (inc. Units) Action (Treatment or Disposal w/Destination Date <br /> r <br /> Tank <br /> Piping <br /> Free Product <br /> Soil <br /> Groundwater <br /> Barrels <br />