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kjdz)G %-111v.7Ldl c Vul i a" •v" <br /> Leaking Underground Fuel Storage Tank Program <br /> I. A encf Information Date: ,?, <br /> Agency name, D Ili `� j1 ddress: <br /> city/statmlaP: 9L� Phone- <br /> Responsible <br /> hone:R onsible staffperson: S T*Me• I <br /> H. Case Information <br /> Site facility name: <br /> Sfte facility address:" <br /> Ria LUSTIS Case No: LocaI Case No: r '? LOP case No: <br /> UAF firing date: 3-2Y43 SWEEPS No: 7 - <br /> R onsible Parties Addresses Phone Numbers <br /> L56 V27 <br /> y <br /> Tank No Size in Gal. Contents Closed in—Place/Removed? Date <br /> Z �}} <br /> 3 I <br /> Ill. Release and Site Characterization Information <br /> Cause and type of release: Y /`� 4 <br /> Site characterization complete? <S�j) No Date approved by oversight agency: y 1 <br /> Monitoring Wells Installed? Yes T� Number. Proper screened interval? Yes No <br /> Frighest GW depth below ground surface: Lowiest depth. Flow direction: <br /> Most Senskive Current Use: <br /> j" Are drinking water wens affected? Yes Aquifer name: ! <br /> Is surface water affected? Yes [Ngo Nearesilatfected SW name: <br /> It <br /> Off—site beneficial use impacts (addressesllocations): <br /> Report(s) on file? ` � No Where is report(s)Bled? Z/ /. S& X04 <br /> Treatment and Disposal of Affected Material �I <br /> Materia! Amount(Include Units) Action (Treatment or Disposal w/Desdnadon) Date <br /> Tank 1 SC' nt G J <br /> Piping 5 n I � <br /> Fme•Product <br /> soil <br /> - s3 z 3 <br /> y II, <br /> Groundwater <br /> NO <br />' Barrels 1 N 0 Nr <br /> i <br /> Exhibit N Page 1 of 2 <br />