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DPCPB M249(I/99)-lU2 wwwalaldovasrg Bev. 02116M <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Page. of <br />L FACHXff IDENTIFICATION <br />BUSINESS NAME (S..FACI=NAMEorD13A-Doingauvnas Ac) 3, <br />FACB,ITYIDA <br />TFF <br />1' <br />oM (tc kcf a LSC <br />TANK NAME' <br />�. <br />_OWNER <br />TANK OWNER ADDRESS <br />41. <br />TANK OWNER CITY ()r �C ]� STATE C ]� <br />ZIP CODE L�F�"� <br />v 14- <br />H. TANK CLOSURE INFORMATION <br />Tank ID # <br />(Atnch edditi9nal roPim <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />oftnva page rot mobs s,an <br />tllrmunkr) <br />INTERIOR <br />ATMOSPHERE <br />I <br />j <br />�IW� <br />745 <br />746a <br />6 <br />7a6b. <br />-J) <br />�(� ]a6c <br />vy �SY/., <br />// ]4n <br />P <br />747b <br />0-11 <br />_J -O <br />]bc <br />READINGS <br />2 <br />Zy `� ] �]46. <br />A'LCT <br />)49a <br />b <br />r 9) b Z 749b. <br />O 1? `49c <br />750a <br />- r) ]SOb. <br />'A]Sac <br />3 <br />751. <br />75h <br />752h. <br />]Sic <br />'/33a <br />7536. <br />]Slc <br />III. CERTIFICATION <br />On co smination of the tank, I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseate and debris. I further certify <br />that <br />the information provided herein is true and accurate m the best of my knowledge. <br />SIGNATURE IFIER <br />e <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />El Yin N No <br />70, <br />NAME OFCER (Not) ]� <br />f)1� / • � , r <br />Name of CUPA, authorized agency, or LIA: <br />761. <br />,,� ;, <br />N/A <br />'TITLE OF CERTIFIER 7ss. <br />If certifier is other than CUPA /LIA check appropriate box below: <br />❑ a. Certified Industrial Hygienist (CIH) <br />761. <br />ADDRESS 956. <br />_" - <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY 7s7. <br />❑ it. Registered Environmental Health Specialist (REHS) <br />E] c. Professional Engineer (PE) <br />PHONE - 75e. <br />i ( l <br />-r <br />❑ E Class II Registered Environmental Assessor <br />g. Contractors' State License Board licensed contractor (with hazardous <br />739. <br />DATE <br />CERTIFICATION TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />761. <br />III ym ft tank intorior etrnmphem"I be rechecked wths<o flble ,as indiralarprior to.,kbeina w .todon the twhk.) Fa Yea ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />7m <br />Nam Grtotr LJ16 (� �,' /4 1-6Z j)e 7 h� 1ia� Q <br />l� <br />'TPS St /e/� tGcc/1cG3 ta! Genf rpvG( lE4kj zt <br />A copy of this certificate shell accompany the took to the recycling/disposal facility and be provided m the agency overseeing took closure (i.e. CUPA or other suthosiud local agency); the <br />owner sa&or operator of the tank system; and the tank removal conteutm. <br />DPCPB M249(I/99)-lU2 wwwalaldovasrg Bev. 02116M <br />