C - Hanford Site

WHC-SD-EN-TI-136, Rev. 0
UNDERGROUND STORAGE TANK
Site Check/Site Assessment Checklist
Tbc pur pose oft this form is to certify the proper invesligatiufl of atn USTstc for thc prcscncc of a release. These acu iviics
shall he conducted in aceordatncc with Chzuptcr 1 73.3(A) WAC. A description of thc various sit uzt ions requiring a site
check or sitc assessment is provided in the guidance document for LIST site checks and site assessments.
This Site Check/Sitc Assessment Chcckli.-t shall he completed and signed by a person rcgistcrcd with the Department of
Ecology to perform sitc asescssmcnts.
Two copies of the results of the site check or site assc.ssmcnt should bc included with this checklist according to the reporting
requirements in the guidance document for LIST site checks and site assessments.
For further information about comipleting this form, plcase contact thc Department of Ecology LIST Program.
The completed checklist should he mailcd to thfe following iddrcss:
1. LIST SYSTEM OWNER AND LOCATION
Underground Storage Tank Section
Department of Ecology
Mail Stop PV- I I
Olym~pia. WA 98504-8711
UST Owner/Operato: IJ~f l3rt.Mggt nf Pgrgy Richlandl nopra-tinnc
Owners Address: 825 Jadwinf
SOWt
Richland
cey
WA
550
P 0. 50-t
99352
zIP CO"
.Telephone: (509 ) 3767387
Site 10 Number (an invoice or available from Ecology if tank is registered):
01 2763
She/Business Name: U.S. Department of Energy - Richland Operations
Sao Address: 825 Jadwin P.O. Box 550
skem
Benton
co.-v~
Richland WA 99352
Ciy om ZIP Cod*
2. SITE CHECKISITE ASSESSMENT CONDUCTED BY:
Registered Person: Ronald M - Mi tchell1
Address: Westinghouse Hanford Company P. 0. Box 1970
Telephone: (509 ) 3765122
Richland WA 99352 -
.11 "A1-4 11AM
B-20
Pag