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11/05/2009 10:16 3105231518 <br />ADAMS SERVICES, INC. PAGE 02 <br />• <br />U14TMD PROGRAMCONSOf.IDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />I. FACRATY IDENTIFICATION <br />W.w��Am,1TYMalawea._a.w.rr_,.._.._. • e..,.. _. _.. <br />TANK OWIll ADDRESS <br />TANK OWNER CITY <br />& STATE. "' ZIp CODE / <br />Ii. TANK CI.09UItE AVFORMATION -te <br />e- f Camsmm�innofFlax <br />ona Vail <br />Con-eenpxtion ofOzyttnaTop CoSn Boom, T0p Cerrter <br />Banmie tntoc, <br />W4Q Ca b LOQ , nh fxn v, ( ,1w <br />)e" isle <br />G.O •"'pav�'d 2) <br />II). CE,RTIFICATtON <br />On emmimtlon oll "ok.I certiry the halt ilivlaoalry nee holo product, sludge, Wk (thin, flaky residual of conk corneum), finuate and d6d,. I foniwr certify that <br />inhxroadun Provided herein in me end aeomate m tlw Icte army kaavfledil <br />SIO A Cell .R STATUS OR AFFILIATION OF CERTIFYING pERSON <br />NAME OF FRTTFIF]t en. Carol in • repre.\enunve of the CUPA. 7tan0vi Rd agency, a UA: tm <br />❑ Yea ;-No <br />Name OfCUPA, ntnhoriaod dgalry. M LIA: ul <br />TITLE OF CERTIFIER /) tv <br />C <br />) <br />L'c-"t" <br />/ C e ADDRESS St'- <br />olha that CUpA / LIA check apgopriate box 1 tc= <br />C6 D <br />& Certified f <br />❑ rduetrial FiyRieniat (CIH) <br />` <br />❑ b. Cerdficd wuty profeaaienal (CSp) <br />C n <br />^ {� <br />(CQ 6 <br />❑ c. Certified Marx Chem gt (CMC) <br />Oka <br />E • <br />❑d Rego"oted Fmiremnenul Heahh 3 liaeiWw (REHS) <br />(, 'Y ' L �� <br />El c. prafoa\innal Enginocr(ph) <br />❑ <br />r Cls» H Regineered EmimnmenYl Atseatot <br />DATE �y <br />CERTIFICATION TIME <br />�B Connaetoty' Stec LieeMe Board licensed eommMor (with hawdoon <br />J <br />/ 1100 <br />aobnmxsmI cc arcadfm) <br />T K VIOUSLY BELD FLAMMABLE OR COMBUSTB3LE MATERIALS <br />)M1\ <br />ditm, M bas inAier ron.rrtac bra ee rodie6d aiw a w,auw Ak pa Mdla.x enw b xee tgna eo.ax W .n ax mik) <br />CERTFiE1JR''.SenTANK_a/dANAO .IN/STRUCTT0NS FOR SCKAp ER �SPOSAL FACRITY, FTC; Ym 13 No <br />W S'E t` p2S7' L� to <br />U /3f>x(�i� <br />raa / s , cpkp, . <br />UPCF(Iw99) 39 <br />Formerly DISC 1249 (6/98) <br />