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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />f <br />Pae 1 of <br />I. FACHdTY IDENTIFICATION <br />BUSINESS NAME (S.. FACO.rry NAMEorDBA—Doing Business M) 3. <br />FACILITY ID# <br />C�114kc Nor <br />TANK OWNER NAME <br />740. <br />M 14 C. PCP cl e L L -C, <br />TANK OWNER ADDRESS 4�i1 <br />(GSG''�� �ii1 X1CiiLt Gl <br />741. <br />TANK OWNER CITY (fir ap T42' <br />STATE A 1D <br />ZIPCODE <br />H. TANK CLOSURE INFORMATION <br />Tank ID # <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />(Anech edditiand F. <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />ofthisggathree�mmethm ke)Top <br />INTERIORj,, <br />ATMOSPHERE <br />I <br />'13n/ATrs <br />O� 745, <br />746.746b, <br />,b <br />_06 � <br />746c <br />U9®(fid <br />747a <br />y <br />747b. <br />U - d <br />747c <br />READINGS <br />2 <br />Z \� 7�r49. <br />.R' LCT <br />- 749a <br />b 06 <br />' 749b, <br />O 49c <br />L <br />'/5as <br />.5 7501h <br />]sac <br />3 <br />751. <br />752e <br />752h. <br />752c, <br />753. <br />7531h. <br />753. <br />HL CERTIFICATION <br />On examination of the tank, l certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseste and debris.. I further certify <br />that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE <br />FIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />i 7 <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />ElYes ® No <br />760, <br />NAME OFC ER (Pm) 754. <br />- j <br />Name of CUPA, authorized agency, or LIA: <br />N/A <br />761. <br />TITLE OF CERTIFIER 755, <br />J <br />If certifier is other than CUPA /LIA check appropriate box below: <br />❑ a. Certified Industrial Hygienist (CIH) <br />762. <br />ADDRESS 56. � <br />_ -. _ _. _ _ <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY 75T <br />- <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE 759. <br />L (1 — L� - ') ;' <br />❑ f Class Il Registered Environmental Assessor <br />mg. Contractors' State License Board licensed contractor (with li rdous <br />759 <br />DATE <br />CERTIFICATION TIME <br />substance removal certification) <br />V d <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />63 <br />(lfyea thennkintmiw eenmpherechall he rerhmkM vnN scombeatible tib indicatorpdurtomikbeingonWueudan the eink) �eg ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764 <br />A copy of this certificate shall secampa r o the tank m the recyclingli ispossl facility and be provided to the agency overseeing tank closure (i.e. CUPA or other aathodud lord agency); <br />the <br />owner and/or operator of the Ina system; end the tank removal contractor. _ <br />UPCF HWF12419 (1/99) -1/2 www.unidocs.org Rev. 02/16/00 <br />