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UNIFIED PROGRAM CONSOLIDATED F0101 <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />1. FACILITY IDENTIFICATION <br />BlIS1NESSNAhtLi(saan:taPArnmrnl+cuFe=noA t7,i+ya-i—n.1 3. � I I <br />=AC11JTY <br />S-300 LLNL EXPERIMENTAL TEST SITE 1 <br />TANK OWNEM NAME. 74J <br />DEPARTMENT OF ENERGY (ATOMIC ENERGY, COMM PPTY) <br />TANK OWNER ADDRESS 741 <br />15999 W. CORRAL HOLLOW RD. TRACY, CA 95376 <br />TANK OWNER CITY TRACY 742. STATE CA "-j 7.IP CODL 95376 744 <br />IL TANK CLOSURE INFORMATION <br />Tank ID # <br />Concentration of Flammable Vapor Concentration of Oxygen <br />(Atuch ada8d=J copra <br />_. <br />� � T Center Bottom T Center Bottom <br />TAN};, <br />`f 1 "r'rc fa 1 <br />Mreeunks) <br />►sl <br />INTERIOR <br />7455 <br />746& 7+66 70 747& . 717b. u7e <br />ATMOSPHERN <br />READINtiS <br />741. <br />2 v C <br />749& 749b 7a9c 73oa 7X12 7ifle <br />�, v ? c . r� �.�i U, � v'ei <br />C? L7 7522& L 1 7322 C� 7J]a L� , 71-A ..f • , 7136 10 Il <br />�fJ <br />a /; `)u 731 <br />(/ <br />III. CERTIFICATION <br />On examination of the link, I certify the tank is visually free from product, sludge, scale (thin, (laky residual of tank contents), rinscatc and debris. I further certify that <br />the insonation provided herein is true arab accurate to the best of my knowledge. <br />S2NARF. OF CERI1F'IER STATUS OR AFTILIATION OF CERTIFYING) PERSON <br />Certifier is a nT msentative of the CUPA, authr rizcd agency, or LIA: 7d" <br />NAMEOF CERTIPIFR irmal 7N.. ❑ Yes ® No <br />-Dent""'.'( i•✓`tI!i- P t I I Name of CUPA, authori7.cd agency, or LIA: 76t <br />•ITIFLE OF CERTIFIER 7" NIA <br />+-c Cyt rr ' r t'�$i Gi Y. IPA / box below 7a <br />If certifier is other than Cl LIA check appropriate <br />ADDRESS [3IL Certified Industrial Hygienist (CIII) <br />IIQe cj t4v.- L (� p ? 1 b. Certified Safety Profcssional (CSP) <br />CITY 717 L❑� c. Certified Marine Chemist (CMC) <br />r (% •' I -��h +' C C d. Registered Environmental Health Specialist (RFHS) <br />73a. <br />PHONE/ [3c. PnhfasionaiFstgituer(PE) <br />/ <br />C0- S L(� L/ 6 IM ❑ f Class 11 Registered Ltivirownrntal Ass=ior <br />719 ❑ g. ContraLturs' State 1. icensc Board licensed contractor (with hazardous <br />DATE CERTIFICATION TIME substance removal certificatiun) <br />-- - — - 763 <br />TANK PREVIOUSLY MID FLAMNIABLU OR COMBUSTIBLE MATL'RIAIS <br />;) }.� <br />(if yes. We uek z..—z..—aero »ptKrr.kail be rc,h.k ed wiee a cmtnnt Mee ph ia6cars pmm t hark bap ca++de&ted on to hark. I [; Ycs ❑ No <br />CF.RTIFIER'S TAN- MANAdEMENT INSTRUCTIONS FOR SCRAP D!?Ai.1:R, DISPOSAL FACILTIY, ETC: 76r <br />A copy of chis certificate shag aeuempaoy the tank to the recyclia;Aigtmat facility and be provided to dw agency overseeing tank clone: (Ce. CUPA or ad= sathori=d local agency): the <br />a%wr and or operator of the tank system: and the tide temuval contractor. <br />UPCF H WF1249 (1199) -112 www.unidoa.org Rev. 02116!00 <br />