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%W \/ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae of <br /> 1. FACILITY IDENTIFICATION <br /> BUSINESS NAME(saeem FAaLM NAME or neA-ming eaarncra Ar) 3 FACILITY IDN r <br /> Tracy high School <br /> TANKOWNER NAME 740 <br /> Tracy Unified School District <br /> TANK OWNER ADDRESS 741 <br /> 1975 West Lowell Ave., Tracy, CA 95376 <br /> TANK OWNER CITY Tracy 742 STATE CA 7U ZIPCODE 95376 79 <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID N Comentrabon of Flammable Vapor Concentration of Oxygen <br /> (Aad addinoral copies <br /> oflhisparefo ranothan To Center Bottom T Center Bottom <br /> TANK procmnks) P oP <br /> INTERIORI 745 746a 3466 946. 747a 1PIE 747c <br /> ATMOSPHERE <br /> READINGS Z 7 74% 74% 749c 75M '/sob 750c <br /> 3 751 752e 9526 752c 753a 1536 753. <br /> HI. CERTIFICATION <br /> On examination of the tank,I certify the tank is visually Gee from product,sludge,scale(thin,flaky residual of tank contents),finseate and debris. I further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency, lbo <br /> P g 4',or LIA: <br /> OF CERTIFIER (Prov) 754 ❑ Yes ❑ No <br /> Juan Sanchez <br /> Name of CUPA,authorized agency,or LIA: 761 <br /> TITLE OF CERTIFIER 155 <br /> Operations Manager If certifier is other than CUPA/LIA check appropriate box below: 762 <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist(CIH) <br /> 1201 E. KentUCky Ave. ❑ b. Certified Safety Professional(CSP) <br /> CITY 51 ❑ c. Certified Marine Chemist(CMC) <br /> Woodland, CA 95776 <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 58 ❑ e. Professional Engineer(PE) <br /> 530-662-2841 ❑ f Class II Registered Environmental Assessor <br /> DATE 759 CERTIFICATION TIME g. Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> 3/15/07 /%30 M 327397 <br /> 763 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (Ifyie,themk 6nerioratenospM1me shill bene-checked vriMacombusdble gu indicmarpnorto. rk being mndumedmr6eiank.) RL Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764 <br /> T <br /> tic - +� ea� �d(e- �L d�r�It , <br /> A copy of this certificate shall accomparry the tank to the recycling/disposal facility and be provided to the CUPA Ifthere is no CUPA,copies shall be submitted to the LIA and authorised <br /> owner/opernoto,ofthe tank stem removal contractor and the recycling/disposal facility. <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />