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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Fear or <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Sessions FACILITY NAME or DIIA-DoingBusiness An) 3 FACILITY ID# 1 <br /> r CSC 0 -2- / 47 Z <br /> TANK OWNER NAME 740 <br /> �oNa �2�s�clgi.J <br /> TANK OWNER ADDRESS �l7L : $"a 0-,3 /5dwy 2 C. S D le7a _ -- <br /> Clev� : <br /> TANK OWNER CITY ©G 0 rax STATE 14J ZIP CODB SZ/ rM <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor <br /> (Anach a floc milia <br /> p Concentration of Oxygen <br /> of(h¢paga e fa mine than <br /> TANK tlu.c unka) Top Center Bottom Top Center Bottom <br /> INTERIOR I �Nf/OG j4 746a 7C r46c 747a 74% Tart <br /> ATMOSPHERE Wry r�% <br /> READINGS Z 6+117 749. 7496 749c 75011 75M 750, <br /> 15�3 C� 751 752a 75n 83c 753. 7536 753r <br /> III. CERTIFICATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank contend),rinseate and debris. I further certify that <br /> 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 CUPA,authorized agency,or LIA: ho <br /> NAME OF CERTIFIER (Prins) 754 <br /> ❑ Yes o <br /> �— a� 761 <br /> Name of CUPA,authorized agency,or LIA: <br /> TITLE OF CERTIFIER 755 <br /> If certifier is other than CUPA/LIA check appropriate box below: 76x <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist(CDH) <br /> 6 ❑ b. Certified Safety Professional(CSP) <br /> CITY 757 <br /> ❑ a Certified Marine Chemist(CMC) <br /> D0 ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 751- <br /> ❑ e. Professional Engineer(PE) <br /> ?46 fv Q d / a❑/E Class II Registered Environmental Assessor <br /> DATE 759 CERTIFICATION TIME p 9. Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70 <br /> (II'M do inak intake atnwaphere dall berxtsclndMI.combusrible gas indicator prior in work beingeaMucBd on die tank) Yea C3No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764 <br /> Fis�,cc��sS vv��sc� w��c�4J Ts4rJl� Fiir/'z�,cLf�l.7Ef�i is Fig <br /> 4go <br /> t2c��r ro ��tuSl� <br /> A copy ofthu certificate shall accompany the took to the recycling/disposal facility and be provided in the CUPA. Ifthers is no CUPA,copies shall be submitted to the LIA and authorized <br /> a en 'owner I.enrat.,of the took s stem removal contractor and the recycling/di osal fscili <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />