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CENTRAL VALLEY REGIONAL WATER QUALITY CONTROL 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 ibe <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 r; <br />LUSTIS Case no. URF filing date Closure date <br />Site name/county <br />Site address 7:City Zip Phone <br />{ <br />Table I - Responsible Party Information x <br />Responsible party <br />Name <br />Address, City, Zip <br />Phone <br />Property owner <br />( } <br />Operator 1 <br />( ) <br />Operator 2 <br />( ) <br />Operator 3 <br />( ) <br />II. Release and Site Characterization Information <br />Tank size(s) Fuel type(s) E s <br />Chemical type(s) and quantity(ies) released <br />fp <br />tp _ <br />Table II - Lateral and Vertical Extent of Contamination <br />Environment Lateral (ft) Vertical (ft) Contaminant Concentration Range <br />Soil mg/kg <br />Groundwater mgli <br />Soil type at the site j <br />Source of drinking water under SWRCB POLICY 88-63:. r <br />Were nearby wells (Domestic, Municipal, Ag, etc.) monitored? Yes No <br />Wells affected (Domestic, Municipal, Ag, etc.)' A <br />Highest and lowest depths to groundwater <br />Seasonal groundwater gradient(s) and direction(s) <br />Name of Regional Water Quality Control Plan {Basin Plan) aquifer. affected (see attached) <br />Surface water impacted? Yes No f <br />Name of surface water body. affected <br />