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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE �77 2 6 Z��6 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATI& <br /> of l <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAM(Saga-FACDAVKAMWO&k-DisBadr—Aa 3. FACII.rrYIDN <br /> _. _. e�� 0 a3 0 Jo S <br /> TANK OWNER NAME Tae. <br /> �_Cr�G7/ul <br /> TANK OWNER ADDRESS �j�/L/��' ��/rL` : �'.5���(7 Tat. <br /> q �9�6(--%- 57t9�+ �t9K 7 X35 2 S 12a Z. <br /> TANKOWNERCITY �G C 79x STATE _ 7k't' yIFCpIDB 5 J 7� <br /> 11. TANK CLOSURE INFORMATION <br /> Tank ID d Concentration of Flamowble Vapor Concentration of <br /> (A�adeknd task. Oxygen <br /> TANK dNb flut.) � TOP Center Bottom Tap F Caller Bo(lonk <br /> INTERIOR I O� 'Mt 74h 7xb. 7d&. 7/h 747b. W7e <br /> ATMOSPHERE rJ _ <br /> READINGS Z 7q. 749a 769b. 79ae. 7soa. ?Xb7 73ft <br /> 7 mi. MI 79b. 7$v, —` lsla Ism Ism <br /> IUL CERTIFICATION <br /> On examination of the tank,I certify the tank is visually Bee from product,sludge,seek(thin,flaky residua(of tank contents),rinseate and debris. I further eerily ow <br /> the infatnation 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,authorized769. <br /> agency,or LAA: <br /> NAME OF CERTIFIER crdot) 7a1. ❑ Yes ® No <br /> TZJ Name of CUPA,audsorizcd agency,or LIA: 761" <br /> TITLE OF wrIPIER _ 755. N/A <br /> If certifier is other than CUPA/LIA check appropriate bore below: 76x <br /> ADDRESS 716" ❑ a. Certified Industrial Hygienist(TILL) <br /> 74), ��G���a ❑ b. Certified Safety Professional(CSP) <br /> rn. <br /> CTI'Y ❑ a Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE 759" ❑ e. Pmfessional Engineer(Pb) <br /> O ❑ f Class II Registered Environmental Assessor <br /> DATE CERTIFICATION <br /> CERTIFICATION TAdE & Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 7" <br /> (I(yq roe ank inleivr amo4hue Yrnll Ea rochrSed w4baoombuYibk sea itMTalm priorro wank beisg covdv4cdm Nur lank) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP ll1iAL[iR,DISPOSAL FACILITY,ETC: 760. <br /> A copy of this canircero ghee accompany the tart to the mycliogldisposd facility amd be provided to the agency overseeing tank closure(i.e.CUPA or dao adhaiced lout agency); The <br /> wooer w0or opealor ofthe tank synam;add the tank removal contractor. <br /> 1 <br /> UPCF HWF1249(1/99)-1/2 wsysv.unidocs.org IRw.0246M <br />