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140%� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> P N <br /> I. FACILITY IDENTIFICATION <br /> BUSINESSNAME Ism r FAaLIW NAM xuu-Ds glwia As) � FACILn'Y IDM � <br /> Joe' s Travel Plaza <br /> TANK OWNER NAME <br /> Dalwinder Dhoot <br /> TANK OWNER ADDRESS Ht <br /> 15600 South Harlan Road <br /> TANK OWNER CITY Lathrop as STATE CA as ZIP CODE 95330 y" <br /> IL TANK CLOSURE INFORMATION t <br /> Turk ID g Commustion of Flammable Vapor Concentration ofoxygm <br /> Uttahankmpia <br /> TANK ami.pyr earsWw m.n TOP Center Batton TOP Curter Bottom <br /> INTERIOR70 <br /> 1 01 ya <10% tae. <10% <10$ y <br /> A <5$ rex <5-1 Nx <5% >.x <br /> READINGS 2 02 <10% tag <10% <10% 7ft e5t tw. <5$ ,seen <5$ nm <br /> 3 nt nee n tsx rsa nab nk <br /> III. CERTIFICATION <br /> On examination ofthe tank,l certify the tank is visually free fmm product,sludge,scale(thin,Flaky residual of tank comma).rirtseate and debris. I further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATJIREOFCERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> z✓`1Y----r — Cmifier ma reptesemative of the CUPA,outhortned agency,a LIX tau <br /> NAME OF CERTIFIER tris) rsz ❑ Yes ® No <br /> Richard A. Walton Name of CUPA,authorized agmcv,or LIA: al <br /> TITLE OF CERTIFIER 155 _ <br /> Vice President Ifccrifer is other then CUPA/LIA check appropriate box below: <br /> ADDRESS ne <br /> ❑ a. Ca[ifxd Industrial Hygienist(CIH) <br /> 3900 Commerce Drive ❑ b Certified Safety Professimal(CSP) <br /> CITY m <br /> ❑ c. Cenitkd Marine Chemist(CMC) <br /> West Sacramento '. ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE ne <br /> ❑ e. Professwnal Engineer(PE) <br /> (916) 372-1888 ❑ f Class 11 Registered Emimmmental Asxssor <br /> DATE see CERTIFICATION TIME ® g. Connectors'State License Board liccrmd contractor(with hazardous <br /> substance removal certification)04/25/07 10: 00 am <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (1rvnbma in .saxplwe dao b ssMcksdsxmamr*asN.jpw, estapri to cert beingmedsmd m Mtas.) ® Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY,ETC: 'Na <br /> Properly dispose of material <br /> A eapy ofdds caEfime"e amps y the tsik w the myding/disposal fKilAy wdbe provided w dx CUPA. Ifdrae is tw NPA,copies shill be submirmd m dw LIA end audweiad <br /> 'aN11R/ ofwe Uak RTM'BI COIIOYwf ml wC II t fYltl . <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />