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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> _ _ d <br /> I. FACILM IDENTIFICATION <br /> BUSINESS NAME t5.me.s FACH-M NAME w DBA-Doiea llvdm All 1 FACILITY D))' 1 <br /> C <br /> • 740 <br /> TANK OWNER NAME <br /> 741 <br /> TANK OWNER ADDRESS <br /> P. o. j3,gx 5v 9 <br /> TANK OWNER CITY Ko Mdh 741 STATE ()A 741 ZIP CODE S/JC' 7u <br /> IL TANK CLOSURE INFORMATION <br /> Tank ID N Concentration of Flammable Vapor Concentration of Oxygen <br /> ►. (Am.b,dd�mmw..pint <br /> er mu pqe r«mo�c m6aa Top Center Bottum -Top Center Bottom <br /> TANK dace"o) <br /> ATMOSPHERE ' 2 K -dips( 746a 6 6/D 746a 746c 747. %D 717b 74 <br /> READINGS 2 748 74% 7496 749c 750s 75th 750. <br /> 9 751 75L 7576 757c 757a 7316 753c <br /> III. CERTMCATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of lank contents),rinseate and debris. 1 further certify <br /> that the information provided herein is nue and accurate to the best of my knowledge. <br /> I. 7NAI��O <br /> OF ERTUgER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> RTIPIER (nim) 754 ❑ Yes No <br /> r 761 <br /> Name of CUPA,authorized agency,or LIA: <br /> 755 <br /> CERTIFIER <br /> V Sim�'f If certifier is other than CUPA/LIA check appropriate box below: 767 <br /> ADDREYS 756 ❑ a. Certified Industrial Hygienist(CIH) <br /> 406 C] b. Certified Safety Professional(CSP) <br /> CIVVVV 757. ❑ c. Certified Marin Chemist(CMC) <br /> d ❑ d. Registered Environmental Health Specialist(RENS) <br /> ` 758 <br /> PHONE ❑ e. Professional Engineer(PE) <br /> d,9 -dio ❑ I. Class 11 Registered Environmental Assessor <br /> gas- <br /> r DATE 759 CERTIFICATION TIMEg. Contractors'Sate License Board licensed contractor(with hazardous <br /> q rr�1 substance removal certification) <br /> 763 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS - <br /> (If M.d.:uit iesuv a morph m dull be m-chvc d whb a.ombemiblc am udomr prim m court W,mMmard oo a.tome.) W 1 Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764 <br /> — A copy of this cenifMW shall accompany the tank o the reryding/disposal facility ab M provided to tae CUPA. If there is rw CUPA,copies shall be sobuuu to.thx o id <br /> authorized a enc o ownm/ nnor of the tanks stem'removal coamu r;and the mycling r dis sal faci KY. <br /> — UPCF(12/99) 39 Formerly DTSC 1.249(6/98) <br />