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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 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 URF filing date Closure date <br /> Site name/county <br /> Site address City Zip Phone <br /> Table I - Responsible Party Information <br /> Responsible party Name Address, City, Zip phone <br /> ' Property owner <br /> Operator I <br /> Operator 2 ( } <br /> Operator 3 } <br /> II. Release and Site Characterization Information <br /> Tank size(s) Fuel type(s) <br /> Chemical type(s) and quantity(ies) released <br /> ' Table 1Q - Lateral and Vertical Extent of Contamination <br /> Environment Lateral (ft) Vertical (ft) Contarnmant Concentration Range <br /> Soil <br /> ft <br /> Groundwater I s mg/l <br /> Soil type at the site <br /> Source of drinking water under SWRCB POLICY 88-53 <br /> Were nearby wells (Domestic, Municipal, Ag, etc ) monitored? Yes No <br /> Wells affected (Domestic, Municipal, Ag, etc ) <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 <br /> Name of surface water body affected <br />