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UNIFIED PROGRAM CONSOLIDATED FORM Ifamrdous Waste Tank Closure Certirlieation Instructions HAZARDOUS WASTE Complete and submit this P page after cleaning any underground or aboveground tank system Subject to Title 22,Division 4.5,Chapter 32,California HAZARDOUS WASTE TANK CLOSURE CERTIFICATION Code of Regulations. Refer to 22 CCR§67383.3 and 23 CCR§2672 for disposal requirements for tank systems Completed Unified Program Consolidated Form(UPCF)Business Activities and Business OwnedOperator Identification(OES Form 2730)pages . Pa c of must be submitted with this form_ Please number all pages of your submittal. (Note: Numbering of the folloMng instructions follows the UPCF L FACMrfY IDENTUFI(-'ATION - data element numbers on this form.) BUSINESS NAME 1s+..drw®.rry envreaaew-nel.a uh iow M) 3. PACB-rry w# I. FACILITY ID NUMBER-This number is for agency use only. Leave this space blank, TANK OWNER NAME 3. BUSINESS NAME-E..ler the complete Facility Name. Na: 740. TANKOWNERNAME- Complete items 740-744 unless all items are the same as the Business Owner information(items 741. TANK OWNER ADDRESS- 111-116)on the Business OwnerlOperator Identification page(OES Form 2730), If the same, TANK OWNER ADDRESS *I 742. TANK OWNER CITY- %Tile"SAME AS SITE"across this section, 743. TANK OWNER STATE- 744. TANK OWNER ZIP CODE- TANK OWNER CITY '� 3TATE '83. Zlp[ppE xat. 745. TANK ID NUMBER 1-3-Enter up to three owner tank ID numbers. These are unique numbers used try the owner to identify each tank. If IL TANK CLOSURE INFORMATION - more than three larks are being closed,complete additional copies of this page (Enter additional tank numbers in 748 and 751.) TWA 11)9 WAms CoacentrationofFlaraniabk Vapor Concermaboaafoxggen 745. CONCENTRATION OF FLAMMABLE VAPOR I-3-Enter interior flammable vapor concentration readings taken at the top,center,and er�wa=re mutl nee TANK daeeeek.) TOP Center Honour. Top Cewe Bottom bonom of the lank.(If more than one tank,enter additional tank readings in 749 and 752.) INTERIOR t H3. TrSv xreh, ll6e. xaxs 7!M1 7/k. ATMOSPHERE 747. CONCENTRATION OF OXYGEN 1-3-Enter interior ovygcn readings taken at the top,center,and bottom of the READTKOS 2 7� 'ate' 7 756a 730e tank,enter additional tank readings in 750 and 753). tank. (If more than 3 At. x5a• l5A xs7: -753. x536 75k_ SIGNATURE-A qualified professional meeting the requirements of 22 CCR§67383.3(f)shall sign in the space provided to certify that the cleaned III.CRR I it ICATION A(s)meet all standards specified in 22 CCR§67393 3(c)(1)and(2). Us C-iinaiim offlit talk I Oenify the tank is+isually free from pmdua,sludge,scale(Ilea.flaky residual of tank cameos),rinseate and debris. I further oerlify that 754. CERTIFIER NAME-Print or type the full name of the person signing the Certification. we olomuuon provided beunm is roc and accurate to Ike beg of m}knmvledge SIGNATURE OF CERTIFIER - 755. CERTIFIER TITLE-Enter the title of the person signing the Certification. STATUS OR AFFILIATION OF CERTIFYING PERSON Cenifuer is a mprese tative of the CUPA audion,"ager y,or LIA: 756. CERTIFIER ADDRESS-Enter the address of the person signing the Certification. NAME OF CERTIFIER rnw 75' ❑Yes ®No 75T. CERTIFIER CITY-Enter the city for the signer's address_ Name of COPA.awhortird agercy,ar LIA leu. 758. CERTIFIER PHONE-Enter the phone number for the person signing the Certification. TITLE OF CERTIFIER N/A _ Hoenifu7 is Ocher filen CUPA!LIA cheek appropriate box below: 7� 759, DATE CERTIFIED-Enter the dale that the Certification as;signed. Enter the time thal the readings were taken. ADDRESS ❑a. Cent6cd Industrial Hygienist(CIH) 760. CERTIFIER REPRESENTS LOCAL AGENCY-Check"Yes"if the person certifying the tank is a representative of a CUPA or authorized local agency.otherwise,check"No." ❑b. Certified Safety Prnfessiosial(CSP) CITY T57. 761. NAME OF LOCAL AGENCY-If certified b a CUPA or other Focal agency,enter the name of the agency, e. Certified Marine Chemist(CMC) Y g ❑d. Registered EnviranmenW Health Specialir(RENS) 762. AFFILIATION OF CERTIFYING PERSON-Check the certification,license,or o PHONE '� 11e. Prefcssiorol Engineer(PE) certifying person belongs,if nal a CUPA orother local agency. organization which the certifier holds or to which the ❑f Class U Registered Fmiranmcmal Assessor 763. TANK HELD FLAMMABLE OR COMBUSTIBLE MATERIALS-Check "Yes"if the tank(s)previously held flammable or combustible materials,otherwise check"No" DATE ' CERTIFICATION TIME ❑g Contractors'State License Board licensed m.naanor(xith ttarardous subaanue removal ceniticatroa) 764. MANAGEMENT INSTRUCTIONS-Provide tank management instructions to The scrap dealer,disposal facility,etc-in this space TANK PREVIOUSLY HELD FLAMMABLE OR.COMBUSTIBLE MATERIALS 76a. arym,u.r.,t: n,,,wdme ora x med.iu,�s�e;w"av,:raor r:uem,mrr,bemrmml,srea u,"vac) ❑ Yes ❑No CERTfftER'S TANK MANAGEMEFI7'INSTRUCTIONS FOR SCRAP pEAl.EIt_DISPOSAL FACn-17'i'.ETC: xu. A Copy of rhir. ute unifdoll v pavy the rank m rhe rwydj"jg6pvd favilir5 wd be pmvided m hhe rgegy e..sx d,rent d=m Ill.CLIPA tr odw aethn'vs8 bol sgmcyy rhe ooae and/or goner of rhe 4ok ah'Mem:and tM lank mmeval cv,gm 4Ur. UPCF HWF7249(1199)-I12 w wildocsorb Rev.07l16m UPCF HWF1249(11W)-2d2 sv. ifidecs,erg Rev:O2l16M