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r <br /> UNIFIED PROGRAM CONSOLIDATED FORM[ <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK (CLOSURE CERTIFICATION <br /> Pae 9 of <br /> L FACH ITY IDENTIFICA'T'ION <br /> BUSINESS NAME(Samaar FACD.rry NA6 ernaA-Dainaaaamaaa As) 3. FACILITY IDN <br /> Cif RC k4v, r LLC <br /> a <br /> TANK OWNER NAME <br /> ]41. <br /> TANK OWNER ADDRESS <br /> .--�-,-ltm �ncllrc� �tia <br /> TANK OWNER CTTY I y ]42 STATE LR 743' ZIP CODE L�,r� "7�C• 744 <br /> H. TANKCLOSURE WFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Atr h additional e-1x <br /> oflhiapeaefermerelhan Top Center Bottom Top Center Bottom <br /> TANK threetmbl <br /> INTERIOR ae,, 'L]45. ]46a ]45b. 146c / ]4]a 7496. 747c <br /> ATMOSPHERE I ''W/I n <br /> READINGS 2 ..a `n C1�49. ]49a ,v v Z ]49M ' e, �749c ]5n750s. r rl. 750b. 750c <br /> G JV L t ]5I. 752a 7752b. ]52c 753a 7536. 753c <br /> 3 <br /> IU. CERTTFTCATION <br /> On examination of the tank,I 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 heroin is true and accurate to the best of my knowledge. <br /> SIONATURE FIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> ]60. <br /> L 1 Certifier is a representative of the CUPA,authorized agency,or LIA: <br /> NAME OF C / IER 0r.) ]w. ❑ Yes ® No <br /> 761 <br /> O / •1, Name of CUPA,authorized agency,or LIA: <br /> TITLE OF CERTIFIER 755. N/A <br /> If certifier is other than CUPA/LIA check appropriate box below: ]@' <br /> ADDRESS 956. ❑ a. Certified Industrial Hygienist(CIH) <br /> i <br /> '— _ ❑ b. Certified Safety Professional(CSP) <br /> CITY s]. <br /> ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE ]5a. <br /> ❑ e. Professional Engineer(PE) <br /> 7 \ % ' ❑ f Class II Registered Environmental Assessor <br /> ]ss, g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS / ]� <br /> IlfyMthemkinrcneraeroophemshailbere-checkedmthawmbusablepin&=rpnorww rkb6i gcondmicdon Metwk.) 0 Yes ❑ No <br /> CBRTE'IER'S TANK MANAGEMENT INSTRllCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: ]w. <br /> i <br /> A coy,of this candficate shall accompar y the tank m the recycling/dispmel fxility mad be provided to the agency overseeing tank elonoss f.e.C31PA or other aefhorissd loml agency); 16e <br /> owner snd/m operator of the took system;and the fork remove]cmnmetcl. <br /> UPCFHWFIIA9(1199)-I2 wwvaanldocs.org Rev.92/16rll0 <br />