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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae or <br /> 1. FACIISTY IDENTIFICATION <br /> BUSINESS NAME(same.FAQ NAME.r DBA-Doing Business As) ). FACILrrY ID# t. <br /> r rW G 740. <br /> TANK OWNER NAME/ <br /> �/`_ �z <br /> let. <br /> TANK OWNER ADDRESS <br /> 0 3C.Y z 5-(� Q <br /> 7e1. <br /> TANK OWNER CITY �Q �//' L STATE C'ft, ZIP CODE 3 G <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable apor Concentration of Oxygen <br /> (Atrxh addidarW copies <br /> of Ws page for more mm Top Center Bosom Top Center Bottom <br /> TANK. dveeonks) <br /> INTERIOR 1 745. 74r- 7e6b. 766c. 7I7a. 747b. 7a7a <br /> ATMOSPHERE 750b. 750- <br /> READINGS 2 leg. 7e9a 7e9b. 769c. 730s. <br /> 3 751. 731x. 7526. 753c. ]53>- 753b. 75X <br /> M. CERTT :CATION <br /> On examination of the rank.I certify the tank is visually free from product,sludge, .:ale(thin, flaky residual of rank contents), rinseate and debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledg <br /> SIGNATURE OF CERTIFIER iTATUS OR AFFILIATION OF CERTIFYING PERSON <br /> 760. <br /> Cettifier is a representative of the CUPA,.authorized agency,or LLA: <br /> 750. ❑ Yes ® NO <br /> NAME.OF CERTIFIER (mar) <br /> 761. <br /> 'fame of CUPA, authorized agency.or LLA: <br /> TITLE OF CERTIFIER 'v 755. N/A <br /> 762. <br /> :f certifier is other than CUPA/LIA check appropriate box below: <br /> �V <br /> ADDRESS 736' ] a. Certified Industrial Hygienist(C -_ <br /> j' r b. Certified Safety Profmsional(CSP) <br /> CITY c c—� 157. <br /> a. Certified Marine Chemist(CMC) <br /> r ] d. Registered Environmental Health Specialist(REHS) <br /> PHONE 759. <br /> e. Professional Engineer(PE) <br /> Zo 7 ❑ E Class II Registered Environmental Assessor <br /> 759. l� �g. Contractors'State Li cense Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> Q K 67. <br /> T PREVIO SLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS �J'1 <br /> (If yes.she onk moaner aunosplm soon be re<I kd with a combasdble gas indicunr prior m work being conducted on die uNc) [ Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILrTY, ETC: 166' <br /> A copy of this ceraf am shall accompany the tank to she recycling/disposal facility and be provided to due agency overseeing tank closure(i.e. CUPA or other authorized local agency): <br /> the owiter and/or operator of the tad:sysmm:and due tank removal contractor. <br /> UPCF HWFI249(1/99)-1/2 http://wvrw.unidoc&org Rev.02116100 <br />