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Mar05 1510:22a <br /> r i p , <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pa <br /> I. FACILITY IDENTIFICATION of <br /> SMNESSNAME(.,m UIYNuatwooA-000saeica Asl s FAcn.rrY IDg I 1, <br /> T Nle OWNER NAME /,uvtr(CrF /3Ly'GD 1Ya <br /> TANK OWNEKADDRFSS Sf C <br /> TANK OWNER CITY �j12Q l+x STATE r/X, rai Gf5 33p "' <br /> zmconr•, <br /> U. TANK CLOSURE INFORMATION <br /> Tank H)P Conccnretioo¢rFbm..ble Va <br /> (Aaalrfea:>d sq:, Pa Cancensrotion oFOAyga <br /> .ram altirarAaeu,s <br /> TANK t.w) TOP Corer "tom Top Center ndtotn <br /> tM'ENOR /^7�M <br /> ATMpSPHAIIi f �OWV an. © l.e. 1,61 u.e 1+'re r.& J N)G <br /> RPADITIG$ <br /> 2 <br /> iJ5 'I.I'A 1111 N9C JS[G <br /> 15¢6 iHk <br /> 3 151. Tsh lIIl ]Sh ]33� 1f31 rYac. <br /> III. CERTIFICATION <br /> Do <br /> the infor m Rescmmidebm d of the u1Ns,l certify the tank is visually floc from pradlcr,slldga,scale(W,,,fl-&-y residual of Imk co¢Imts),rilurdfe a1d dchia 1 runha ccoify that <br /> herein a tr MA amarale Io the ben of my kumvlalgo ! <br /> SIGNATU CERTIF STATUS OR AFFILIATION OF CERTIFYING PFRSON et <br /> Certlri"is/sepre5eo126V0 Oftf CUPA,amllorEzOd agency,or LLA: Ira { <br /> OF 'CIFIER rl 1� J+ <br /> ❑ Yes tg No <br /> Name ofCUPA,m0=k ed ag=cy,or LlA: nn. <br /> TrYLB OF CERTIFIER Tss. <br /> �/ A VA <br /> C • =L C Ifct¢tifterisolhwthm COPA/LlAcbmkepp lliakbmbdotr TR. <br /> ADDFly rx ❑a. CutifirdlssductrmIH <br /> 3/ / Q K Ccrtirkd Safety Psefamimal(CSI') <br /> CITY / xsz ❑ e Cerrifted Madre Ctlamist(CMC) <br /> G 00 C,4 . // Q d. Aegipe ed Enrim anenyl}lealds Spce¢lis (AEHS) <br /> IMiONfE/) �/ l/ �` �j 15K Q e. Pmftssi¢tul Engi¢eR(PE) <br /> f0 0 / /7511. �� / S J Q 1' Class 11 Registued Emirornrintal Assrssor <br /> DATE' <br /> CERTIFICATION TIME Cosaraclo5'Smfo lisc¢sc Boatel licroscd caltractw(tvlth hazardRas <br /> to sdbSMkv leinw4i anifigazlon] <br /> TANK PAEYIOUSLY HELD I'LiMMABLE OR COMBIIST113 F MATERIALS tn. <br /> url.>w.tM�..�o,.7m11.,,�,.,n mcaas.d...n.anai,aeai laeimsoraaer�o.mlla:s emdueleE®ws oras <br /> Yes Q No <br /> 4T?ATIFIER'S TANK/MNAtaTIslERr IN51'RUCTfONS FOR SCRAP DGLCR,DISPOSAL F.\CILITY,ETC: <br /> lel-V Ss-1 /NFa iiF.> 4,7,--1 CpL . ✓Y S es. <br /> ���r�� GCF�9n1 gn J 139SI, C/Nf S l?1 LfJ �I., IfJ;Pfa/�� <br /> /r <br /> A roPY ofmn m,{it-enb,W�acourylnY tb�mtrorM rcyclilgrAhposnl Mfitl'dtd W RoridW to rb{racy LovetRr.;n/ <br /> bi'aCrOMFMODCR10r aFt1Y lit 5}nd[wd nF act O=a.1 ccaoc . aCbra(GIa]YR�A C((PA ar¢IkrraYlbpli(d IO41 aariyl: I1. <br /> UPCF HWFl249(L99)-12 <br /> III1P:!lsrvw.nofdocaosg Rcv.021Ira00 <br />