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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pec of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(swuu maurry NAMem DBA-Dftu.nmsm) y FACILITYIDA I' <br /> �A CO o 3 la <br /> TANKOWNERNAME ���"AC�'!S� �/f/(t'/(5 ��"�/� T ✓G�G1'f2r//C� ]*�. <br /> TANK OWNER ADDRESS/137 S- ]ai. <br /> TANKOWNERCH'Y ]az STATE Com. ]a'' ZIPCODE <br /> 11. TANK CLOSURE INFORMATION <br /> Tank INI Concentration of Flammable Vapor Concentration of Oxygen <br /> (AuanddllionY rgrk° <br /> °rl"v°r0f°p1O�° Top Center Bottom Top Center Bottom <br /> TANK aa+rw+;al <br /> INTERIOR 1 y.t ]a3. Naa p-s ]u6 O ]dia .�' ]a]a �1IM1 ]a]c <br /> ATMOSPHEREI V V <br /> READINGS 2 o© ua. J.� 11 NSh. ]ave ]Sna ]snh r� <br /> 3 Jsr. v ]s]a 753°: ]s]k ]sJc <br /> Ill. CERTIFICATION <br /> On exermloetion of the tank,I certify the tank Is visually free from product,sludge,scale(thin,flaky residual of tank contents),riaseate and debris. I further certify that <br /> the information provided herein is tmeand accurate In the but of my knmviedge. <br /> SIGNAT T7 STATUS OR AFFILIATION OP CERTIFYING PERSON <br /> Certifier is representative oflhe COPA,authorized agency,or LV+: ]� <br /> E OF .rlFIER(W.) M ❑ Yes ® No <br /> ]°L <br /> `/ Name ofCUPA,authurizcdagency, <br /> TrrLEOFCERTIFIER ]� N/A <br /> Cd (D Ifcmdri r is other than CUPA/LEA check appropriate box belo`tr./ az <br /> ADDRESS rsn ❑ a Certified Industrial Hygienist EC E I V E C <br /> o 3-5'7 b. Cvlified Safety Professional(CSl') <br /> CITY ]n ❑ AUGa Certified Marine Chemist 0 ,_015 <br /> �� ��� / ❑ d Registered Environmental Health Specialist(REES) <br /> PHONE> ()y t''S7/�/' ]dx ❑ a. ProfoswmalEng(neer(PE) --NVIRONMENTA! <br /> V / 3 6�6 � 7 p Assessor Tri nCC11 rJTA tCar" <br /> �! ❑ f. Clara It Registered Environmental Assessor <br /> DATE rsu CERTIFICATION TIME IP"Q Contraaora'State l.icrnsc Board licensed contractor(svith haaardorn <br /> subsumce removal axlification) <br /> rf3. <br /> TANK PREVIOUSLY HEIR FLAMMABLE OR COMBUSTIBIE MATERIALS <br /> lHrq aurut Yecbr�'mgM1^°mdl asrMiaavd wilM1arwnbwlibleav indkampriorW.mkaey mndalutov aurin¢.) Yea ❑ No <br /> CERTIFIFR'STANK MANAGEMENT INST'RUCt'IONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: r^a <br /> 7�r9�z 1S •¢5�'[/ i Soo�soo evOL S'/JF N£,t) eir-'-1 <br /> fNvv.c /'3693-1 <br /> ,_ ' r O®27-3 96 23 E 'B <br /> A copy ofrhu owtificaw r1wR arT°a'P°aY Au Wk to the recydinglaiaposel hcilky and be provided to the a6encl'oretueinH lank el—(i.e.CUPA ar orhar nurhwiad kcal ageneyJ the <br /> owner andloropmatearrhe Writ rynara and McLnk¢men oeoft cW. <br /> UPCF HWIr1219(1199)-In http:/Avrvw.unldoa.org Rev.0111000 <br />