CENTRAL VALLEY REGIONAL WATER QUALITY CONTROL BOARD

CASE CLOSURE CHECKLIST

Leaking Underground Storage Tank Program

 

This checklist, CASE CLOSURE letter, and the Unauthorized Release Report Form (URF) is to be retained by the Regional Board and Local Implementing Agency as documentation of release and subsequent closure action. All files and reports will be placed on microfiche for review.

I. Case Information

LUSTIS Case no. URF filing date Closure date

Site name/county

Site address

City Zip Phone

Table I - Responsible Party Information

Responsible party Name Address,City,Zip Phone
Property owner      
Operator 1      
Operator 2      
Operator 3      

II. Release and Site Characterization Information

Tank size(s) Fuel type(s)

Chemical type(s) and quantity(ies) released

Table 11 - Lateral and Vertical Extent of Contamination

 Enviroment Lateral(ft) Vertical(ft) Contaiment Concentration
Soil      

mg/kg

Groundwater      

mg/

Soil type at the site

Source of drinking water under SWRCB POLICY 88-63

Were nearby wells (Domestic, Municipal, Ag, etc.) monitored? Yes No

Wells affected (Domestic, Municipal, Ag, etc)

Highest and lowest depths to groundwater

Seasonal groundwater gradient(s) and direction(s)

Name of Regional Water Quality Control Plan (Basin Plan) aquifer affected (see attached)

Surface water impacted? Yes No

Name of surface water body affected

III. Soil Remediation Information

Soil remediation method(s)

Volume treated and/or removed

Contaminated soil disposal site

If contamination is remaining, describe concentration range and volume (cubic yards or meters)

Table III - Maximum documented contaminant concentrations in soil before and after cleanup

 Contaminant

 Method

used

 Before

(mg/kg)

 After

(mg/kg)

 Depth

(ft)

  Contaminant

 Method

used

Before

(mg/kg)

 After

(mg/kg)

Depth

(ft)

 TPH (Gas)          Benzene        
 TPH (Diesel)          Toluene        
 Other fuel          Ethylbenzene        
 Heavy metals          Xylene        
 Other          Other        

IV. Groundwater Remediation Information

Groundwater remediation method(s)

Volume treated and/or removed

If contamination is remaining, describe concentration range and volume (gallons or liters)

Table IV - Maximum documented contaminant concentrations in groundwater before and after cleanup

 Contaminant

 Method

used

 Before

(mg/kg)

 After

(mg/kg)

 Depth

(ft)

  Contaminant

 Method

used

Before

(mg/kg)

 After

(mg/kg)

Depth

(ft)

 TPH (Gas)          Benzene        
 TPH (Diesel)          Toluene        
 Other fuel          Ethylbenzene        
 Heavy metals          Xylene        
 Other          Other        

V. Closure

Does Regional Board concur with closure? Yes No

Rationale for closure

Location of reports on file (Agency/Room)

County Staff person Phone

Regional Board office Staff personPhone

 

UST Req for Closure Check List.html