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Case Closure Su~iman <br /> 'r Lealdng Underground Fuel Storagnk Program <br /> ' I. Aqency Information 9 <br /> Date: <br /> Agency nameL. Address: PQ, APOK 3� <br /> Cy /ZIP. Phone: d q 033 <br /> 17 <br /> Responsible staffperson: /11'�j,Q True: # <br /> 11. Case Information <br /> Site facility name: <br /> Site facility address: �7 , <br /> RB LUSTIS Case No: Local o: LOP Case No: <br /> URF filing date: SWEEPS No: j <br /> Responsible Parties Addresses Phone Numbers ` <br /> 3 <br /> Tank No Size in Gal. Contents Closed in—Place/Removed? Date <br /> , em d� l -26 Q3 <br /> 2 Sri <br /> 111. Release and Si a Characterization Information <br /> Cause and type of release: <br /> Site characterization complete? YeNo Date approved by oversight agency: 3 <br /> Monitoring Wells Installed? Yes No Number: C> Proper screened interval? Yes No <br /> Highest GW depth below round surface: <br /> 9 P 9 0 Lowest depth: Flow direction: <br /> Most Sensidvve Current Use: <br /> Are drinking water wells affected? Yes No Aquifer name: <br /> i <br /> Is surface water affected? Yes No NearesVaffected SW name: <br /> Off—site beneficial use i acts (addresses locations): f <br /> Report(s)on file? Yes No' Where is report(s)filed? ' <br /> Treatment and Disposal of Affected Material i <br /> Material Amount(Include Units) Action (Treatment or Disposal w/Destination) Date <br /> Tankkf el <br /> Piping o crs d <br /> Free Product <br /> Soil <br /> Groundwater <br /> f <br /> Barrels <br />