|
UNUS PROGRAM CONSOLIDATED FOR* Luly�irr W
<br />HAZARDOUS WASTE SEP 14 2016
<br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION
<br />L FACILITY IDENTIFICATION _
<br />BUSINESS NAME(seme as FACn.t7Y NAh7E or DBA - Doing Business N) ' rRULllr trJx I ' I LI
<br />�L4,2 SIo 7A)o 2Syi /4;/ S Gt AL 000 , 5 3/ ? 740
<br />TANK OWNER NAME
<br />S
<br />TANK OWNER ADDRESS
<br />�-'7 V s Gd 743 SATE ,l�a LIP CODE
<br />TANK OWNER CITY V
<br />. a.v �r �enoe TNT, 11T}MATi(1N
<br />ut. tJaxairia.e+iiv,.
<br />)n 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 />he information provided herein is We and accurate to the best of my knowledge.
<br />IlGNATURE OF E IER — STATUS OR AFFILIATION OF CERTIFYING PERSON
<br />760.
<br />n z w Certifier is a representative of the CUPA, authorized agency, or LIA:
<br />(Plim)
<br />'ITLE OF CERTIFIER
<br />I _ e../
<br />:ITY
<br />zea. ❑ e. Professional Engineer (PE)
<br />rNE
<br />� D � ` � �% / ❑ f. Class II Registered Environmental Assessor
<br />739 v �g. Contractors' State License Board licensed contractor (with hazardous
<br />.ATE CERTIFICATION TIME substance removal certification)
<br />/, oil 3�c�G1 763.
<br />PRE IOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS
<br />'Yes, the tank interior awospbrra shdl be ,,lnecked with a combustible gu indic.far prior to work being wldubW oo the tank)
<br />Yes ❑ No
<br />7
<br />754 ❑ Yes ® No
<br />Name of CUPA, authorized agency, or LIA.:
<br />755. N/A
<br />if certifier is other than CUPA / LIA check appropriate box below:
<br />756. ❑ a. Certified Industrial Hygienist (Clef)
<br />❑ b. Certified Safety Professional (CSP)
<br />757. El c. Certified Marine Chemist (CMC)
<br />f,G ❑ d. Registered Environmental Health Specialist (REHS)
<br />761.
<br />ERTIFIER'S TANK MANA2Gr INSTRUCTIONS ruK St KP r uc CN usorv' � 1,07 0/0 �l
<br />3—.2,e5-A6e,0a i7�,;Js�� Tam ,, /� f — 69&&6
<br />copy of this certificate 3111111 acwmpany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other authorized local agency); site
<br />MPv andrnr m,..vsanf of lb- I—V evvf<m• en4 tan M.V vs.n n.r a mn—",
<br />Tank ID #
<br />(Attach additional copies
<br />of this page for more than
<br />Concentration of Flammable Vapor
<br />Concentration of Oxygen
<br />Top
<br />Center
<br />Bottom
<br />Top.
<br />Center
<br />Bottom
<br />TANK
<br />INTERIOR
<br />three bake)
<br />� 745.
<br />1
<br />© 746a.
<br />7466.
<br />74611.
<br />o
<br />747a.
<br />7476.
<br />e. 9
<br />747e.
<br />ar. 9
<br />kTMOSPHERE
<br />5.5 a
<br />749.
<br />749x.
<br />749b.
<br />749c
<br />75011.
<br />7"b.
<br />750c.
<br />READINGS
<br />2
<br />731.
<br />752a.
<br />752b.
<br />752a
<br />753..
<br />753b,
<br />753c.
<br />3
<br />— ----
<br />ut. tJaxairia.e+iiv,.
<br />)n 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 />he information provided herein is We and accurate to the best of my knowledge.
<br />IlGNATURE OF E IER — STATUS OR AFFILIATION OF CERTIFYING PERSON
<br />760.
<br />n z w Certifier is a representative of the CUPA, authorized agency, or LIA:
<br />(Plim)
<br />'ITLE OF CERTIFIER
<br />I _ e../
<br />:ITY
<br />zea. ❑ e. Professional Engineer (PE)
<br />rNE
<br />� D � ` � �% / ❑ f. Class II Registered Environmental Assessor
<br />739 v �g. Contractors' State License Board licensed contractor (with hazardous
<br />.ATE CERTIFICATION TIME substance removal certification)
<br />/, oil 3�c�G1 763.
<br />PRE IOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS
<br />'Yes, the tank interior awospbrra shdl be ,,lnecked with a combustible gu indic.far prior to work being wldubW oo the tank)
<br />Yes ❑ No
<br />7
<br />754 ❑ Yes ® No
<br />Name of CUPA, authorized agency, or LIA.:
<br />755. N/A
<br />if certifier is other than CUPA / LIA check appropriate box below:
<br />756. ❑ a. Certified Industrial Hygienist (Clef)
<br />❑ b. Certified Safety Professional (CSP)
<br />757. El c. Certified Marine Chemist (CMC)
<br />f,G ❑ d. Registered Environmental Health Specialist (REHS)
<br />761.
<br />ERTIFIER'S TANK MANA2Gr INSTRUCTIONS ruK St KP r uc CN usorv' � 1,07 0/0 �l
<br />3—.2,e5-A6e,0a i7�,;Js�� Tam ,, /� f — 69&&6
<br />copy of this certificate 3111111 acwmpany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other authorized local agency); site
<br />MPv andrnr m,..vsanf of lb- I—V evvf<m• en4 tan M.V vs.n n.r a mn—",
<br />
|