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.�. cRE r`'VE tD ((Date / <br /> APR 24 2015 L EGET V E , <br /> UNIFIED PROGRAM CONSOUDAFMRONMENTAL MAR 16 20 <br /> HAZARDOUS WASTE IHFA!Tu r)FORgTAAl=KIT <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATIONNVIRONME TAL <br /> Is�A'Ttal FOJa rw-r <br /> Pae of <br /> I. FACILITY IDENTIFICATION - <br /> BUSINESS NAME(am.FACflay NAMarooaA-DftR.iava AO a• FACI.ITYRN <br /> t. <br /> g 4e coo Z 3 <br /> TANKOWNERNAME 74t <br /> TAN�V -1�c—Gi`� <br /> xu. <br /> TAN OWNER CITY S dC �d 9az I STATE ]u. ZIP CODE/SQL CJ ]u <br /> 7,401 06 11. TANK CLOSURE INFORMATION <br /> Tank ID N Concentration of Flammable Vapor Concentration of <br /> ua.rh ddaiaaal�. Oxygen <br /> TANK rias m�1w )aam TOP Center Bottum Top Center BnOom <br /> INTERIOR '� tis. ]sits HQh ]Jas nna sd]b )a]c <br /> ATMI]srxORn - <br /> KFAVmU5 2 ].ts. Nva T4-9 N9c Smit rsnh ]Sun <br /> t <br /> 3 ]ar. "- ]sh ]sIh ]S>a ]sk >nk 79c <br /> 1111. CERTIFICATION <br /> On matimmion ofthe tank.I certify,the tank is visually free from product,sludge,Seale(thin,flaky residual of lank contents),rinseaw and debris. I further ecnify that <br /> the information provided herein is true and accumt to dor best of my knowledge. <br /> gCEJRTTFIER <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> CaOfier is a representative ofthe CUPA,authorizedas xa <br /> g ncy,or LTA: <br /> ]5Q <br /> ❑ Yes ® No <br /> Name ofCUPA,authorized agency,or LLA: ]LI. <br /> W. N/A <br /> Ifcertifteris otherthan CUPAILIA check appropriate box bebrr. ]m' <br /> ADD rx. <br /> 2�j ❑ a Certified Industrial Hygienist(CM) <br /> Lo (3® S7 ❑ b. Certified Safety Professional(CSP) <br /> CITY ]S]. ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Spxiatist(REHS) <br /> PHONE AA nit ❑ e. Professional Engineer(PE) <br /> tCERTIFOR'S <br /> y / ❑ f. Class If Registered Environmental Assessor <br /> CERTIFICATION TIME COn"04Or5State LiMue Board Licensed wntmetor(with hazardous <br /> substance removal certification) <br /> PREVIOUSLY HEIR FLAMMABLE OR COMBUSTI LE MATERIALS GS+ // d/Lows Wnbrvlmopharsidl bv.<hmlw with v canbwtwc .Wd wpivr Work tor$w wamrus) YOS ❑ No <br /> TANK MANAGEMENT INSTRUCI')ONSFOR SCRAP DWLERDISPOSAL FACILITY,ETCk r�/�LF��,�sF�, c�f���-r,, v�y f�vr'Ty.g�✓o /s e'c,✓sT.sdc>�� m, "` <br /> A mpY ofthu wdificmo stall vacorvpany d.rook m mo rayclry•/di poW 6cilitY sari be provided w mo NermY mcraednµtook donor(i.e.CUPA ar dhmwtivbd Local vgweYk 1h9 <br /> ower aMloropcvvtor ofthc t.m ryncm;sari the twk.cnroval c9ohvctor. <br /> UPCF tnVFI249(1/19)-72 hltp:/M'wvv.unldocs.asg Jam.02/16/00 <br /> 12 <br />