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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Pae of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3- <br />ID# <br />I <br />Lawrence Livermore National Lab (Site 300) <br />EILITY <br />TANKOWNERNAME <br />740 <br />Department of Energy <br />TANK OWNER ADDRESS <br />741 <br />15999 W. Corral Hollow Rd <br />TANKOWNERCITY Tracy 74-. <br />STATE CA 143 <br />ZIP CODE 95376 <br />743 <br />II. TANK CLOSURE INFORMATION <br />Tank ID # <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />(Attach additional copies <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />of this page for more than <br />three tanks) <br />INTERIOR <br />1 <br />810ATF 745 <br />' 746a. <br />�o <br />9 7466. <br />�o <br />C 746c <br />D <br />p 0/ 747a <br />�0 <br />�1 q 747b <br />Yo <br />747c <br />20.1"/o <br />ATMOSPHERE <br />AD01 <br />1 /O <br />oL 1 <br />READINGS <br />2 <br />748 <br />749x. <br />7496. <br />749c. <br />750x. <br />750b <br />750c <br />3 <br />751 <br />752x. <br />7526. <br />752c. <br />753x. <br />753b <br />753c <br />III. CERTIFICATION <br />On examination of the tank, 1 certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseate and debris. I further certify <br />that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />❑ Yes ® No <br />760 <br />NAME OF CERTIFIER (Print) 754. <br />Matthew Fechser <br />Name of CUPA, authorized agency, or LIA: <br />761 <br />TITLE OF CERTIFIER 755.N/A <br />Certified Industrial Hygienist <br />If certifier is other than CUPA / LIA check appinpriate box below: <br />a. Certified Industrial Hygienist (CIH) <br />762 <br />ADDRESS 756.® <br />15999 W. Corral Hollow Rd <br />❑ b. Certified Safety Professional (CSP) <br />EI c. Certified Marine Chemist (CMC) <br />CITY 757. <br />Tracy <br />❑ d. Registered Environmental Health Specialist (RENS) <br />[1 e. Professional Engineer (PE) <br />PHONE 758. <br />(925) 423-7844 <br />❑ f. Class If Registered Environmental Assessor <br />Elg. Contractors' State License Board licensed contractor (with hazardous <br />759. <br />DATE <br />CERTIFICATION TIME <br />substance removal certification) <br />12/8/2020 <br />10"(0 AM <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />763 <br />(If ycs, the tank interior atmosphere shall be re -checked with a combustible gas indicator prior to work being conducted on the tank.) ® Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764 <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other authorized local agency); <br />the <br />owner and/or operator of the tank system; and the tank removal contractor. <br />UPCF HWF1249 (1/99) - 1/2 www.unidocs.org Rev. 02/16/00 <br />