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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />I. FACILITY IDENTMCATION <br />BUSINESS NAME (Same as FACILITY NAME or DSA - Doing sustrtess AS) 3. FACILITY ID# ' L LL <br />TANK OWNER NAME r y p <br />TANK OWNER ADDRESS _ <br />STATE lJ/ 723. ZIP CODE 7 <br />TANK OWNER CITY �Y <br />Tank ID # <br />(Attach additional copies <br />of Nis page for more than <br />TANK three tanks) <br />INTERIOR 745. <br />ATMOSPHERE I <br />REAWNGS I <br />751., <br />of <br />1. <br />740. <br />741. <br />II. TANK CLOSURE INFORMATION <br />Concentration of Flammable vapor it Concentration of Oxygen <br />Top Center Boaom Top Center Botrom <br />oda, 7469. I <br />747a I, 747b. 747,. <br />749h. 748n. 7502. I noo. <br />752b. 7529. , 7532 I 753b. <br />j3 <br />M. CERTIFICATION <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 <br />that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />754. <br />NAME.OF CERTIFIER (Print) <br />755. <br />TITLE OF CERTIFIER <br />756. <br />ADDRESS <br />/-7 <br />757. <br />CITY <br />758. <br />PRONE <br />758. <br />DATE CERTIFICATION TIME <br />'� 4" 515 t -f <br />T PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIAL <br />(If yes. the tank interior atmosphere shall be rc-checked with a combustible gas indicator prior w work being. <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALS <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility and be <br />the owner and/or operator of the tank system; and the tank removal contractor. <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />760. <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />❑ Yes ® No <br />761 <br />Name of CUPA, authorized agency, or LIA.: <br />NIA <br />762 <br />If certifier is other than CUPA I LIA check appropriate box below: <br />❑ a. Certified Industrial Hygienist (CIH) <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />❑ d. Registered Environmental Health Specialist (RENS) <br />❑ e. Professional Engineer (PE) <br />❑ f. Class II Registered Envirownental Assessor <br />Contractors' State Li cense Board licensed contractor (with hazardous <br />substance removal certification) <br />763. <br />i <br />:onducied on the tank.) Yes ❑ No <br />R, DISPOSAL FACILITY, ETC: 764 <br />irovided to the agency overseeing tank closure (Le, CUPA or other authorized local agency); <br />UPCF HWF1.49 (1199) -11.. <br />9 http://www.unidoes-org Rev. 02/16100 <br />