C - Hanford Site

t C 0L 14
WHC-S-EN-TI-136, Rev. 0
UNDERGROUND STORAGE TANK
Permanent Closure/Change-In-Service Checklist
The purpose of this form is to certify thc proper closure/change-in-servicC of unrderground storage tank (UST) systems.
These activities must bc condticted in accordane with Chapter 173.300) WAC. Washington State UIST rules require the
tank owner or operator to notify Ecology in writing 30) days prior to closure or change-in-servie of tanks. This must he
donc by completing the 30 Day Notice formt (ECY 010- 155).
This Permnanent Closure Checklist shall be completed and signed by a Liceeised D~ecommnissioning Supervisor. Thc supervisor
shall be on site when all tank p~ermanen~t ctosure/change-in-servicc activities are being conducted. The firm which
cemploys the licensed supervisor shall also be licensed by the \Vashtnglon Slate Department of Ecology as a Service Provider.
If any of the activitics listed below have been supervised by a different licensed supervisor, a separate checklist
must be filled out and signed by the licensed supervisor p~erformuing those activities.
For further information about completing this form, pleatse contact the Department oif Ecology LIST Program.
A separate checklist must be comnpleted for each LIST system (tank and associated piping), except that UST systems at
one site may bc reported together by completing page 2 of* this foi in separately for cacth system. The completed checklist
should be mailed to the following address within 30) days of the completion of the closure or chiange-in-service.
Undeground Storage Tank Section
Department of Ecology
Mail Slop PV- I I
Olympia, WA 98504 -871 1
1. UST SYSTEM OWNER AND LOCATION
Site Owner/Operator: U.S. Department of Energy Field Office, Richland
Owners Address: 825 Jadwin 550
Sheet
P'C Sax
Richland WA 99352
-C Sim*. ZICode
Telephone. 509 )376-7387
Shte 10 Number (on invoice of available from Ecology if tank is registered): 012763
Site/Business Name: U.S. Department of Energy Field Office, Richland
Site Address: 825 Jadwin, P.O. Box 550 Benton
Subet
cow*f
Richland WA 99352
dyq slaV ZIP Co
2. TANK PERMANENT CLOSURE/CHANGE-IN.SERVICE PERFORMED BY:
Firm: Westinghouse Hanford Company LicenseNumber: S001592
Address:
R...icland WA 99352
cioy Shate ZIP co".
Telephone: (509 ) 376-7411
D. A. Riley Decommissioning t14000778
Licensed Supervisor: _________ ______________ License Number: __________
B-23
EcYoo, 0t& 12 (12 page
1970