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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Page of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3- EILITY ID# I <br /> Lawrence Livermore National Lab(Site 300) <br /> TANKOWNERNAME 740 <br /> Department of Energy <br /> TANK OWNER ADDRESS 741 <br /> 15999 W.Corral Hollow Rd <br /> TANKOWNERCITY Tracy 742 <br /> . STATE CA 143 ZIP CODE 95376 744 <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than TANK three tanks) Top Center Bottom Top Center Bottom <br /> INTERIOR 810ATF 745 ' 746a. 9 746b. C 746c p 0/747a �1 q 747b O 747c <br /> ATMOSPHERE 1 AD01 �o �o D �0 1 /O oL 1 Yo 20• O <br /> READINGS 2 748 749a. 749b. 749c. 750a. 750b 750c <br /> 3 751 752a. 752b. 752c. 753a. 753b 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 that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> NAME OF CERTIFIER (Print) 754. ❑ Yes ® No <br /> Matthew Fechser Name of CUPA,authorized agency,or LIA: 761 <br /> TITLE OF CERTIFIER 755. N/A <br /> Certified Industrial Hygienist If certifier is other than CUPA/LIA check appinpriate box below: 762 <br /> ADDRESS 756. 0 a. Certified Industrial Hygienist(CIH) <br /> 15999 W. Corral Hollow Rd ❑ b. Certified Safety Professional(CSP) <br /> CITY 757. ❑ c. Certified Marine Chemist(CMC) <br /> Tracy ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 758. ❑ e. Professional Engineer(PE) <br /> (925)423-7844 ❑ f. Class If Registered Environmental Assessor <br /> DATE <br /> 759. CERTIFICATION TIME Elg. Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> 12/8/2020 I 0"(0 AM <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 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: 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); 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 />