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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Page of <br /> I.FACILITY IDENTIFICATION <br /> t. <br /> BUSINESS NAME.(same as FACILITY NAME on DBA-Duing l3u...') 3' FACILITY ID N <br /> 740, <br /> TANK OWNER NAME <br /> 74I- <br /> TANK OWNER ADDRESS <br /> 744. <br /> 732. STATE - .. 743. ZIP CODE <br /> TANK OWNER CITY <br /> 11.TANK CLOSURE INFORMATION <br /> Usk IDM Concentration of Ffammablc Vapor Concentration of Oxygen <br /> (Auxin add;wmal cgdcs Center Bottom <br /> of chis fsse for lame tdan Te Center Bottom Top _ <br /> TANK bete tanks) p <br /> INTERIOR I - 745. 7463 746b. 746c. 7473 : 747b. .` T47c. <br /> ATMOSPHERE 74yh 74 W. 750a Mb. y 750h <br /> READINGS Z les 7493 <br /> 1 TSL <br /> 1323 752h 732c. 753x 753b. 753h <br /> 755x 7343. 754h 754r. <br /> 755h 755h <br /> 111.CERTIFICATION <br /> On examinadon of the tank,I certify the lank is visually free from product.sludge,scale(thin.flaky residual of tante contents).rinsate and debris.1 further certify <br /> that 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 CU PA,authorized agency,or L!A: 76()- <br /> NAM&OF CERTIFIER(Print) Y 754° ❑ Yes Da No <br /> 761. <br /> Name of CUPA,authorized agency,or L1A: <br /> TITLE OF CERTIFIER 755. N/A <br /> if certifier is other than CUPA/LIA check appropriate box below: <br /> 762. <br /> ADDRESS 736. ❑ a. Certified indusiial Hygienist(CIH) <br /> 17 b. Certified Safety Professional(CSP) <br /> CITY 757. ❑ C. Certified Marine Chemist(CMC) <br /> 0 d- Registered Environmental Health Specialist(RENS) <br /> PHONE 758. ❑ e. Professional Engineer(PE) <br /> E) f. Class 11 Registered Environmental Assessor <br /> DATE 759. CERTIFICATION TIME ❑ g, Contractors'State License Board licensed contractor(with <br /> hazardous substance removal certification. <br /> r ' <br /> 763. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> ((f yes,the tank interiorstmosphere shall be re-checked with a combusdble gas indicator prior to work being completed on rhe taAk 1 <br /> Yea ❑ Na <br /> T64, <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC, <br /> VASCO ROAD LANDFILL TANKSIPIPING MEETS TITLE 22 REQUIREMEN"T"S <br /> 4001 N.VASCO ROAD CRUSH WITH HEAVY EQUIPMENT <br /> LIVERMORE,CA 94550 <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure(i.e.CUPA or other <br /> authorized local agency);the owner and/or operator of the tank system;and the tank removal contracror. <br />