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12/18/2001 10:40 209467"18 AGE STOCKTON PAGE 02/02 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION 1 <br /> Pairs ! of <br /> _. <br /> I. FACILITY Y IDENTIFICATION <br /> BUSINESS <br /> �NAME <br /> j(s�m s,FAnuaw Nnxa 0,r oeA-osme eaai„e,7 A71 3_ FACILITY(Die 711111 <br /> t, <br /> TANKOWNERNAME <br /> TANK OWNER OWNER ADDRESS 741. <br /> - d4f�S�� <br /> TANKOWNERCITY 7dQ STATE >es' ZIP CODE TM' <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oz <br /> Wuxi,sddaional wp. .._ Oxygen <br /> afthia Yeae r ).,I. I'noTANK rhreelxksTOP Center Bottom Top Cents Bottom <br /> INTERIOR )T' adds. 7470, 747b, 7 e <br /> ATMOSPHERE _ <br /> READINGS 2 49. _ 'a719b. Tape. 730.. 7506, 7soe <br /> 2 -- 7m. 75F'— 752b.zb. nae. 75la. rtes n30, <br /> III. CERTIFICATION <br /> On examination of the tank,I certify the tank is visually froe from product,sludge,scale(thin,flaky residual of tank contents),rh aeste and debris. 1 further certify that <br /> the infomvtion provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF CERRTIFIIEE/R�p.� STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> - Conifer is a repmsrntative of the COPA,authorized agency,or LIA: Tao' <br /> NAME OF CERTIFIER (m.o 1S4. Yes❑ Yes ® No <br /> lilP //(�, Name otCUPA,authorized agency,or LID: <br /> 761. <br /> TI <br /> TLE OF CERTIFIER 735' N/A <br /> lfeer iffier is other than CUPA/LIA check lax' <br /> o f appropriate box below: <br /> ADDRESS 156 C1a. Certified Industrial Hygienist(CIH) <br /> A37 S ❑ Is. Certified Safety Professional(CSP) <br /> CITY /' __..�. ❑ c. Certified Marine Chemist(CMC) <br /> `�,a ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE .Y --7317- <br /> �}�/r/fyd q q ps ,yq/yam ❑ e. Professional Engineer(PE) <br /> o" L l 3 0+ V U",.J ❑ f Class it Registered Environmental Assessor <br /> DATFFFjjj 59' CERTIFICATION TIME 00. Contractors'State License Board licensed contractor(with hazardous <br /> //I/� substance removal certification) <br /> TANK REVIP�U�SL.Y.��HF.Ij)FLAMMABLE OR COMBUSTIBLE MATERIALS 7 <br /> tlrrss,lha tank mtvto`a� Vhcm shall be rt.ohcckcdwith a mmbenibk in indicmry priorw%06 brine eoa0uwed on IM1,leek) ❑ Yee ❑ No <br /> CERTIFIER-'.;TANK MANA EMRNT INSTRUCTIONS FOR SCRAP OEALER,DISPOSAL FACILITY,ETC: lad. <br /> A copy orthis rarttftcese shalt scwmpmy the tank to the recyclina/disposal facility and be provided ro the e¢etuy overseeing tank closure(1-9 CUPA or other authorized tout egenay); rbc <br /> owne.and/or npantor ofthe tank syston:and the tank removal conmcior. <br /> UPCF H W FI249(1199)-112 http://www.unldoca.oag Rev.02116MO <br />