Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM - <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICA �__ <br /> I. FACILITY IDENTIFICATION I or <br /> BUSINE$$NAME iSa euPACjLITY,N Or DEA-DolnaautIhwAs). a .FACILITYID# 'S <br /> AJ �o <br /> TANK OWNER NAME <br /> /. 740 <br /> TANK OWNER ADDRESS <br /> 741 <br /> TANK OWNER CITY STATE 2 7a. 74s �,,. .. <br /> C!{� ZIP CODF 7"S JAI✓ <br /> 11. TANK CLOSURE INFORMATION <br /> 'Dank E)# Concentration of Flammable Vapor <br /> TANK cflhisafsmH <br /> (Aiuch a e r-mdroaConcentration of Oxygen <br /> re tthhan •TO .. <br /> P Center Bottom <br /> INTERIOR 745 7460 Top Center Bottom <br /> ATMOSPHERE 146h 7460 e,-j 7470 Q 747b Q 747. <br /> READINGS 2 748 ,.,.y 749a 7496 719c <br /> _ v 7500 7506 ® ]SOc <br /> / 3 ! 751 t�) 7=. 7526 732e <br /> ( v �q 7550 D 75Jb ® 75]. <br /> L/�4�1 G✓i1E Z S %� I(I. CERTIFICATION �, Ca. .✓fC��i <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank contents),rinseate <br /> the information provided herein is and the best of my knowledge. and debris. I further certify that <br /> SIGNATURE - STATUS OR AFFILIATION OF CERTIFYING PERSON " <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> N OF CER IER (Pdnq _ 754 ,,..__// - <br /> ❑ Yes No <br /> �^ <br /> i Name ofCUPA,authorizb.d agency;or LIA: 761 <br /> TITLE OF CERTIFIER � � 755 <br /> If certifier is other then COPA/LIA check a ro nate box below: <br /> PP p � 70 <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist <br /> > ❑ b. Certified Safety Professional(CSp) <br /> CITY 7'D 11 a Certified Marine Chemist(CMC) <br /> L ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE ^� 7sa ❑ e. Professional Engineer(PE) <br /> V „ o`- S �/ ❑ f. Class I Registered Environmental Assessor <br /> 759 ��{{tt . <br /> CERTIFICATION TIME /q) B• <br /> DATE Conhactors'State License Board licensed contractor(with harudous <br /> 1,1,5 ?/A/ \substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> (1lya,�hc wkimedaamwrphrn:rhea b.rxhak.d wiN awmbutoblegu hMicakapdarb wmkbeing caduckdan Oe Hort) Yes ❑ No <br /> CERTffIER'S TANK MANAGEMENT INSTRUC'FIONSFOR SCRAP DEALER,DISPOSAL FACILITY,III 760 <br /> Z.-vvc�%icc-() f C r lcl>fJ C1'1i'5 <br /> A wpy ofthk artificate shall accompany We rank to the recyclirsg duposal'facility sed bepmvidedb the LT1PA:Ifthero is W COPA,eoPiea shall7O <br /> a en ownhmieed to a LIA and authol - <br /> er/o razor of the tank s ter <br /> m• an oval.aontaetoraadtherec clip /du osalfmili . <br /> UPCF(12/99) 39 Formerly DISC 1249(6/98) <br />