C - Hanford Site

WHC-SDI-EN-TI-136, Rev. 0
This page must be completed separately for each tank permanently closed (decommissioned) or change-
In-service at the site. For additional tanks you may photocopy this form prior to completing.
3. TANK CLOSURE/CH-ANGE.IN-SERVICE INFORMATION
1. Tank ID Number (as registered with Ecology): 10ON-SS-28 2. Year installed: 1 976
3. Tank capacity in gallons: 2000______________ 4. Date of last use: 12/90__________
5. Last substance stored: Ulae Gsoie6. Date of clostue/change-in-seivice: 7/1 7/91
7. Type of closure: Closure with lank Rlemoval [I In-place Clostite Change-in-Seivice L
8. It in-place closure is used, the tank has been filled with the following substance: N/A
9. If change-in-service, Indicate new substance stored in tank: N/A
10. Local per mit (s) (it any) obtained from: N/A
Always contact local authorities regarding permit requirements.
11. Has a site assessment been completed? Yes Eli No
Unless an external release detection system is operating at the time o1 closure or change in service, and a report is provided as specified in WAC
173-360-390, a site assessment must be conducted. This site assessmenit must be cotiducted by a person registered with the Department of
Ecology to perform site assessmeonts. Remilts of tits site ass essapent must be included will) tite Site Assessment Checklist (ECY01O-158).
4. CHECKLIST
Each item of thc following checklist shall he initialed by the licensed stipervisnir whose signature appears below.
___________________ ___ __________________ Yes No NA*
1. Has all liquid been removed from product lities?
2. Has all product piping been capped or removed?
3. Have all non-product lines been capped or removed?
4. Have all liquid and accumulated sludges been removed from the tank?
S. Has the tank been properly purged or inefted?
6. Have the drop tube, fill pipe, gauge pipe, pumps and other tank fixures been removed?
7. Have all tank openings been plugged or capped? NOTE: One plug should have 1/8 inch vent hole.
8. Have all sludges removed from the tank been designated and disposed of in accordance with the stale
of Washington's dangerous waste regulations (Chapter 173-303 WAC)?____ ___
9. If removed, was tank properly labeled and disposed of in accordance with all applicable local, state
and federal regulations? LABELED AND AWAITING FINAL DISPOSAL ________
Iftemn not applicable
I hereby certify that I hravne been I/ne licensed sitpen'isor preset opt site dttring tire arbove listen pernianent closure activities and to
tihe best of rmy knowledge threy have beenl conldrilcen in colliplhurnCC Ivitirtill applicable stale rrndfcderal lirs, regulations and
procedures pertaining to rtndergrortinnl trrage tanik.
Personrs surinitting false inrformratin tire srtbject i peptalriesurnder Cjter 173.360 111/1 C.
5. ADDITIONAL REQUIRED SIGNATURES
ECYOIe-,ea 111 B-21 Ipage 2