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I <br />EP <br />LLLL���� <br />EYED Irk® UNIFIED PROGRAM CONSOLIDATED FORM <br />L�7 UIS HAZARDOUS WASTE <br />U <br />IL 5 2010 HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />VIR <br />N1 AAW1 <br />PENo <br />of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NA`ME(umeu vACILf N"X9,DBA-DolceBmInwA,) I <br />FACILITYIDN <br />I <br />a <br />_ <br />TANK OWNER NAME 171 C IL(1"j �eF4Z F5';,�q 2—, Xrt/(/gs 740 <br />�/lg7�'/g, <br />TANK OWNER ADDRESS 741 <br />�_p z _ <br />TANK OWNER CRY S.. 74` 1 STATE (f3 t43 ZIP CODE S/ZZ <br />ox 6EN <br />•�/W746b <br />Tank ID p ' <br />(Aoeeb Ndltl-nY reptg. 9,lel , <br />o(a�bPKefarm-mN <br />TANK a -a ww) Top Top Center Bottom <br />INrEAIOR ]45 <br />ATMOSPHEREREADINGS <br />�6]476 <br />]47c <br />7 748 <br />15r 4750. <br />r� 75pb 7�ooO <br />J� <br />751 <br />711. <br />711 /S 79c <br />' <br />� L <br />..a w.=W11 vn O me tang, t earthy In' tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseate and debris. 1 fimher certify that <br />the information provided h 'o is true and accurate to the best otmy knowledge <br />;map <br />ATUS OR AFFILIATION OF CERTIFYING PERSON <br />ertifier is a representative of the CUPA, authorized agency, or LIA: 760 <br />Q Yes AND <br />me ofCUPA, authorized agency, or L1A: 761 <br />TITLE OF CERTIFIER 733-1 <br />C;L L 4 If cenificris other than CUPA / LIA check appropriate box below: }62 <br />ADDRES �/ 7 756 ❑ a. Certified Industrial Hygienist (CIH) <br />o/\ -3 � / ❑ b. Certified Safety Pmfessional (CSP) <br />CITY 757 Q c. Certified Marine Chemist (CMC) <br />Z-bL • / ❑ d. Registered Envimumental Health Specialist (RENS) <br />PHONE re77 Cid J 7s O e. Professional Engineer (PE) <br />V C� �� / / ❑ f. Class 11 Registered Environmental Assessor <br />DA'PE 759 � Contractors' Stale License Board licensed contractor (with hazardous <br />CERTIFICATION 1')IvIE <br />/'� substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 767 <br />(7fYm,a,.lsia heuwr.Cnmp6ncrhJl bemcM JW wi�ryawn,b Obf.au Wlpmrpia m we, being-on4ucb4 an ut. Wlc)YCS ❑ NO <br />f`FRTIRIFR R <br />.--mopaoy <br />ao <br />UPCF (17/99) 39 Formerly DTSC 1249 (6/98) <br />