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REMOVAL 2016
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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KETTLEMAN
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1833
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2300 - Underground Storage Tank Program
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PR0540845
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REMOVAL 2016
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Entry Properties
Last modified
12/6/2018 1:28:46 PM
Creation date
11/1/2018 10:54:08 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
REMOVAL
FileName_PostFix
2016
RECORD_ID
PR0540845
PE
2361
FACILITY_ID
FA0023349
FACILITY_NAME
TSUTAOKA, MARY
STREET_NUMBER
1833
Direction
W
STREET_NAME
KETTLEMAN
STREET_TYPE
LN
City
LODI
Zip
95240
APN
03133009
CURRENT_STATUS
02
SITE_LOCATION
1833 W KETTLEMAN LN
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
Scanner
WNg
Supplemental fields
FilePath
\MIGRATIONS\K\KETTLEMAN\1833\PR0540845\2016 REMOVAL.PDF
QuestysFileName
2016 REMOVAL
QuestysRecordDate
6/10/2016 7:13:28 PM
QuestysRecordID
3110772
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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un I <br /> 03 <br /> UNIFIED PROGRAM CONSOLIDATED FORM'AY 0 5 <br /> HAZARDOUS WASTE ? }l r;' <br /> HAZARDOUS WASTE TANK CLOSURE CEArfU SA ON rY 4 <br /> Pee of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(snore ns FAOLrIY NAME rn DRA-Mirs Dusinm As) 3. FACiLfCY ID# 1. <br /> TANK OWNER NAME 7411.n <br /> TANK OWNER ADDRESS <br /> —- 741. <br /> TANK OWNER CITY lag' STATE 7J3' zrP COD744. <br /> 11. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> Wladr addlrional m(+ic. <br /> °rte) se rOf°°°IhP° To Canter Bottom To Center Bottom <br /> TANK tbrcetarkr) p p <br /> INTERIOR / ,745. 7460_ 746b. 744. 747& 7476, 747c <br /> ATMOSPHERE. i `7 U 0 m <br /> READINGS2 g. 719& 749h o 749. 754& 750b. ` 750k. <br /> I i <br /> 3 751. 752& 752h 752c. 753& 7536. 753, <br /> I11. CERTIFICATION <br /> On examination ofthe 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 O ERTI STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is t)representative of the CUPA,authorized agency,or LIA: 7611 <br /> 117 V\ <br /> NAME OF R'I�lFL& tprini) 7� 154. ❑ Yes �No <br /> J <br /> ��^ Name of CUPA,authorized agency,or LIA: 761. <br /> TITLE OF CERTIFIER W. <br /> W N/A <br /> ccg(� //("51 if certifier is other than CUPA/LIA check appropriate box below 70. <br /> ADDRES 46 7u <br /> ❑ a Certified Industrial Hygienist(CIH) <br /> Q 315 17 ❑ b. Certified Safety Professional(CSI') <br /> CCl'Y 757. <br /> ❑ a Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 75s. ❑ e. Professional Engineer(PE) <br /> Cl 75— <br /> ❑ f Class Il Registered Environmental Assessor <br /> DATE <br /> 759 CERTIFICATION TIME Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> J <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 7f3' <br /> (Ir}es,Cho lurk imerior ain ospheradmll bore-chcckcd with 0 combuMible Sw indiczd r prior to%ort being cuM-Eadon Ibe rant`) Odl Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT'INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 744. <br /> A copy of this codificato shall accompany tho tank w the recycling/disposal tbcilily and be provided to tho agency overseeing tank dos re(i.e.CUPA or other auttwrizcd local agency); the <br /> owrter muilor operator orthe tank%y acres and the tank removal contractor. <br /> UPCF MVF1249(1/99)-112 http://wtvw.un)doc&org Rev.02/16/00 <br />
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