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UNIF IED PROGRAM CONSOLIDATED FORM <br /> ELAZARnOUS WASTE <br /> EAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> ps e �f <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FAQ `FAME or DBA-Doing 11oon9 nal 5' <br /> FACII.ITY B7# I I L <br /> TW <br /> TANK OWNER NANS /J n <br /> TANK OWNER ADDRESS <br /> 0 3o x z SS <br /> �/ lag /� ;a3. ZIP CODE 74. <br /> TANK OWNER CITY &/Q e r`//2 STATE C/ c1 S�zS <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable -'apor Cowentration of Oxygen <br /> (AoaN a"UoW caPia <br /> a hoer page for more mm TOP Caner Bosom Top Center Bottom <br /> TANK. 7a7a.dux oaksh ; la/b. <br /> ATMOSPHERE I 1 747c <br /> ,� <br /> INTERIOR f _ �7as. ta6a. la6b. O <br /> SIS ZL <br /> READINGS 7ag. 749& 74%. ta9e. I 15ha 7500. 75aa <br /> 2 751. 73h 7391 I 777e. 79a. 753b. I 757-. <br /> 3 <br /> III. CERTIECAMON <br /> On aaminadon of die rank.I certify rhe rank is visually free From product,sludge. _ale(thin, flaky residual of rank comma),riuseare and debris. I Cunha cerdty <br /> that the information provided herein is true and accurare to the best of my knowledg <br /> SIGN ATL T i TATUS OR AFFII.IATION OF CM-1T BFMXG PERSON <br /> 791. <br /> :.-trdfier is a representative of Elie CUPA..authorized agency,or LIA: <br /> OF R (Ih+m <br /> lx' Cl Yes E NO <br /> 761. <br /> Name of CUPA.authorized agency,or LLA: <br /> 755. N/A <br /> TRT.E OF CERTIFIER <br /> _ lbt <br /> c - :f certifier is other than CUPA I LIP.check appropm are box below: <br /> 7w. <br /> ADDRESS a. Ctrdfied Industrial Hygienist(CIH) — . <br /> - - <br /> b. Certified Safety Professional(CSP) <br /> CITY <br /> c. Cadfied Marine Chemist(CMC) <br /> d. Registered Environmental Health Specialist(REHS) <br /> PHONE 75" e. Professional Engineer(PE) <br /> LL Jc �' f1 / f. Class ll Registered Environmental Assessor <br /> 759. / v Contractors' Stare Li cense Board licensed contractor(wit hazardous <br /> DATE CERTIFICATION TIME �a substance removal certification) <br /> 4SLY TAa PREVELD FL.,LM TABLE OR COMBUSTIBLE MATERIALS �� <br /> (I(w.tie rant immiar ammpMe shwa t»is.hactN wrk a wmbustible Sera indicmor prior m wart baro;condua�an de tett) Imo' YeS C3 No <br /> bA <br /> T INSTRUCTIONS FOR SCRAP DEALER. DISPOSAL FACII.TTY, ETC: <br /> CERTIFIER'S TANK MZ_ XGEMEN <br /> A copy of this cemfiate shad accompany the oak m the Teye�pgl�p°Sm hciLLry and be provided m the agency ovetseemg rank closure(i.e.CUPA or other autaorisd loaf:°enoyl' <br /> the owner ad/or opetamr of the rank system:am the rank removal con=or. <br /> Rev.0:(16100 <br />