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mow <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WAS'T'E TANK CLOSURE CERTIFICATION <br /> Page—of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(same as FACQUTY NAME or DBA-Doing Business As) 3 FACILITY ID11 t <br /> c <br /> aao <br /> TANK OWNER NAME <br /> 741 <br /> TANK OWNER ADDRESS <br /> f, C, &.) hD� 3e MD <br /> TANK OWNER CITY 742 STATE 0A 743 Z[P CODE iS 74-0 <br /> II. TANK CLOSURE INFORMATION <br /> t Tank[D H Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> ofthis page far mare than -fop Center Bottom Top Center Bottom <br /> TANK three) <br /> INTERIOR l 745 746a L 11/1 7 7466 746. 747a �. (/7 747b 747c <br /> ATMOSPHERE I <br /> READINGS 7 748 749a 749b 749c 750a 750h 750c <br /> 3 75t 752a 752b 752c 753a 753b 153. <br /> ' III. CER'T'IFICATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank contents),rinseate and debris. I further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> ' TURE OF CERT I STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative oft <br /> ftIl�CUPA,authorized agency,or LIA: 760 <br /> V <br /> 754 l.Q� <br /> NAME OF RTIF[ER (print) El Yes No <br /> ' t lfi Q <br /> Name of CUPA,authorized agency,or L[A: <br /> lA 755 <br /> TITLE ERTIF[ER <br /> 762 <br /> Mite I n If certifier is other than CUPA 1 LIA check appropriate box below: <br /> ADD 756 S ❑ a. Certified Industrial Hygienist(ClH) <br /> Gt1 ❑ b. Certified Safety Professional(CSP) <br /> v• � 757 <br /> C Y ❑ c. Certified Marine Chemist(CMC) <br /> I H � � r ❑ d. Registered Environmental Health Specialist(REHS) <br /> ` ` L/ 758 e. Professional Engineer(PE) <br /> PHONE ❑ g ( <br /> ' VI n — f. Class 11 Registered Environmental Assessor <br /> 759 g. Contractors'State License Board licensed contractor(with hazardous <br /> 01 9/v 2— <br /> DATE CERTIFICATION TIME substance removal certification) <br /> 763 <br /> TANK PRE IOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> ' (If yes,the tank interior atmosphere shall be rechecked with a cambustihle gas indicittar pnor to work being rnndacted on the tank.) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764 <br /> )�)Cir x /VV,. <br /> A wpy of this cenific of shall—ompatty the tank to the recycling/disposal facility and be provided to the CUPA. If there is oo CUPA,copies shall be submitted w the LIA and authorized <br /> ' agency;owner/opertar of the ranks stem;removal contractor and the sec clip /disposal facility, <br /> UPCF(12199) 39 Formerly DISC 1249(6/98) <br /> S <br />