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CENTRAL VALLEY'-mi(EGIONAL WATER QUALI'I'`N• ONI'TROL BOARD <br />CASE CLOSURE CHECKLIST <br />Leaking Underground Storage Tank Program <br />This checklist, CASE CLOSURE letter, and the Unauthorized Release Report Form (URF) is to be <br />retained by the Regional Board and Local Implementing Agency as documentation of release and <br />subsequent closure action. All files and reports will be placed on microfiche for review. <br />I. Case Information <br />LUSTIS Case no. <br />URF filing date Closure date <br />Site nalll% o my l/�n���r �'�cr � �v S 7� <br />V <br />Site address 1 �-"f <br />k' Zip C / Phone <br />Sic <br />Table I - ResDonsible Party Information <br />Responsible party <br />Name <br />Address, City, Zip I Phore <br />Property owner. <br />I Concentration Range <br />Soil� e.T�c� <br />- �i;C -fi's <br />Operator 1 <br />f <br />mg!kg <br />I ( ) <br />Operator 2 <br />I ,�-Z� �' <br />�t�r <br />Operator 3 71 <br />I (( ) <br />II. Release and Site Characterization Information <br />Tank size(s) l SCC; ��G; Fuel type(s) <br />Chernical type(s) and quantiry(ies) released ` l `�?m� A' n (7 a ccn� ' \I <br />Table II - Lateral and Vertical Extent of Contamination <br />Environment <br />Lateral (ft) <br />I Vertical (ft) <br />Contaminant <br />I Concentration Range <br />Soil� e.T�c� <br />- �i;C -fi's <br />mg!kg <br />Groundwater <br />(:.3`GC ��3 <br />I ,�-Z� �' <br />�t�r <br />I ��-S.s�,et1-.Ez mgll <br />Soil tyre at the site CiR6t`� <br />Source of drinking water under SWRCB POLICY <br />Were nearby wells (Domestic, ?Municipal, Ag, etc.) monitored? Yes No X <br />Wells affected (Domestic, Municipal. Ag, etc.) <br />Highest and lowest depths to groundwater <br />Seasonal groundwater gradient(s) and dire <br />Name of Regional Water Quality Control Plan (Basin Plan) aquifer affected (see attached) <br />\11- -- - S rl . V -oc 1. \l riR,--,i !1 <br />Surface water impacted'? Yes No <br />Name of surface water bodv affected - A- <br />