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UNUPEED (PROGRAM CONSOLMATEID FOIMM <br />I "ARDOLTS WASTE <br />HAZARDOUS WASTE TANK (CLOSURE ICE+RTMCAT-TON <br />ge 7 g <br />Paof . <br />I. FACII,I 1DFNTIFICATION _ <br />BUSINESS NAME ISssoon FAcu.rrvwAh sroaA-Doinaae,iness As) t -FACILITY <br />ID# <br />�)�'i FSC PG4 <br />TANK OWNER NAME - <br />TANK OWNER ADDRESS <br />TANK OWNER CITY �y tax' STATE l.#'E 7n' Z[P CODE��'�tr_' <br />741. <br />IL TANK CLOSURE INFORMATION <br />Tank ID 0 <br />Concentration of Flammable Vapor Concentration of Oxygen <br />(Anadodd�nanal .pin <br />Top <br />Center Bottom Top <br />Center <br />Bottom <br />TANK <br />o(bispyefer moa �nan <br />tl�rte tanks) <br />INTERIOR <br />ATMOSPHERE <br />ryry ���� 715. <br />�Ivv <br />]aea <br />�n <br />746k. _ M6d. 7471 <br />- _ ✓� l '�C r� .p <br />' / <br />, f ,a]E <br />J .. <br />-1-0 <br />74h <br />READINGS]4fi <br />a <br />Z-' ln.c'th <br />la9a <br />]49h. ^ ]49c ]50, <br />v - . - t- G <br />,Sob. <br />]50c <br />7 <br />751. ,511 <br />- 151T75In - 7511 <br />75Ib <br />- bII. CERTIFICATION <br />On examination of the tank, I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), notate and debris. I further certify <br />that <br />the information provided herein is true and accurate to the beat of my knowledge. <br />SIGNATURE IFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a, epresentleive of the COPA, authorized agency, or LIA'. <br />❑ Yes ® No <br />760 <br />NAME OF C IER (flint) 7sa <br />~ <br />Name of CUPA, authorized agency, or LIA: <br />N/A <br />76` <br />755. <br />TITLE OF CERTIFIER <br />i <br />Ifcertifier is otherthan CUPA / LIA check appropriate box below; <br />76x. <br />❑ a. Certified Industrial Hygienist (CIH) <br />ADDRESS - 7 756- <br />_, --� —_ <br />❑ It, Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist(CMC) <br />CITY 157. <br />❑ d. Registered Environmental Health Specialist (RENS) <br />❑ e. Professional Engineer (PE) <br />PHONE 1$9' <br />c (} 9 :\ ' <br />❑ f. Class II Registered Environmental Assessor <br />g. Contractors' State License Board licensed contractor.(with hazardous <br />I <br />ass <br />DATE <br />CERTIFICATION TIME <br />.substance removal certification) <br />_— <br />7e1 <br />TANK"PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS j <br />n, ,me silien.,am.,hoso,ball he,sctoiksd with a occlostibievpaindiumrpn.m.wrk hona..dooed on the oils) / Yea ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764. <br />li <br />A copyA copy of this eertificate sheli accompany tiro tank m the ox lingldispmal razility and ne provided to the agency avelsecing tank closure (ie CUPA or other aatham<d locni agency); <br />be <br />owner end/. operator of be task system; told the took remavnl emthac[or. __ <br />J <br />ii HWFH249 (1/99)- Ud www.00idoca.org Rex 97116/00 <br />