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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae of <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME(same es FAClury NAME or DBA-Doing Buaineu As) 3 FACILITY IDH t' <br /> ]40. <br /> TANK OWNER NAME <br /> 741. <br /> TANK OWNER ADDRESS <br /> 7az. STATE 743. Z[P CODE 744 <br /> TANK OWNER CITY <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID k Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> ofthupageformorethan Top Center Bottom Top Center Bottom <br /> TANK once tanks) <br /> INTERIOR I ]45. 746. 7466. 74k- 747. 7476. ]4]c. <br /> ATMOSPHERE <br /> READINGS 2 746. 749. 7496. 749c. 750. 7506. 750c. <br /> ]51. 752. 7526, 752c. 753a 7536. 753c. <br /> 3 <br /> M. 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: 750. <br /> NAME OF CERTIFIER (B54.iot) ❑ Yes No <br /> 61. <br /> Name of CUPA,authorized agency,or LIA: <br /> TITLE OF CERTIFIER 755. N/A <br /> 762. <br /> If certifier is other than CUPA/LIA check appropriate box below: <br /> ADDRESS 756' ❑ a. Certified Industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CSP) <br /> CITY 75]. <br /> ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d Registered Environmental Health Specialist(RENS) <br /> PHONE 758. ❑ e. Professional Engineer(PE) <br /> ❑ f Class II Registered Environmental Assessor <br /> 759. E] 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 /> (Ifyc,the conk interior amosphere shill be mchmked wah a combastibke gas mdicatorpriorto work being condoned on the rack) ❑ 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(1199)-112 www.unidoc&org Rev.02/16/00 <br />