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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 FACLLrrY NAME or DBA-Doing Business Aa) 3, FACILITY ID# <br /> TANK OWNER NAME 740. <br /> TANK OWNER ADDRESS 741. <br /> TANK OWNER CITY ]4z. STATE 741. ZIP CODE 744. <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID 4 Concentration of Flammable Vapor Concentration of Oxygen <br /> (Atlnch additional copies <br /> of Nis page for More Men To Center Bottom To Center Bottom <br /> TANK para forks) P P <br /> INTERIOR 1 745. 746. 7466. 746c. 747. ]496. 747.. <br /> ATMOSPHERE <br /> READINGS 2 ]4a. 749. 7496. 749c. 750. 7506. 750c. <br /> 3 751. 752. 7526. 752c. 753. 7536 753c. <br /> III. CERTIFICATION <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 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 LLA: 760' <br /> NAME OF CERTIFIER (Pam) 754. ❑ Yes ® No <br /> Name of CUPA,authorized agency,or LIA: 761. <br /> TITLE OF CERTIFIER 755. N/A <br /> If certifier is other than CUPA/LIA check appropriate box below: 762. <br /> ADDRESS 56, ❑ a. Certified Industrial Hygienist(CIH) <br /> ❑ It. Certified Safety Professional(CSP) <br /> CITY 57 ❑ a Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REFS) <br /> PHONE 759, E] e. Professional Engineer(PE) <br /> ❑ f Class II Registered Environmental Assessor <br /> 759. ❑ g, Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> 763. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> ([lyes,MefWc interior wnosaere shall be rccheckMwith a combustible gis iniicmr Prior w vmrkbeing conducted on the tools) ❑ Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764. <br /> A copy of this certificate shall accomparry 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 HW F1249(1/99)-1/2 www.madocs.org Rev.02/16/00 <br />