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UNIFIED PROGRAM CONSOLIDATED FORM <br /> RAZARD <br /> HAZARDOUS WAS °US WASTE <br /> TE TANK CLOSURE CERTIFICATION <br /> BUSINES$NAMEtSameu FACILI7y YANEor DBA_ I. <br /> FACILITY IDE'�CATION Pae of <br /> Doing Business As) 3. FACILITY IDN <br /> TANK ow (- <br /> NER NAME <br /> cT ;an. <br /> TANK OWNER ADDRESS I <br /> rAxK OWNER CIrY T G C I <br /> 741. 1 <br /> el ]42. i <br /> STATE �/�/. 7a3' <br /> Tank ID,f III ZIP CODE If, <br /> . Ta�NK CLOSUR: INFORMATION <br /> 1 <br /> (Amon atldiueml.*, I Coacentration.of Flammable vapor <br /> o(rhis page inn mnre C <br /> iAHH op enter <br /> oboe Concentration of Oxygen <br /> , T <br /> .A O PHERE ) I 745. I a6z I ]46b. 1 Bonom]a&. Top I Center I Bottom <br /> RFADP7CS <br /> 21 ]a— 749x. ;a]z © ]a]c. <br /> 3 ]sl. .� 52a 750a. I 750b. 750c. <br /> 752b. - <br /> - 1 753a. 153b. <br /> I Sac. <br /> III CERTIFICATION <br /> On examination of the rank, I certify the rank is visually free from product,sludge, scale ` <br /> that the information provided herein is true and accurate to the best of my knowledge. ( Flaky residual of rank contents), <br /> rinseate and debris. I further cettifv j <br /> SIGNA RT <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency, or LIA: <br /> �fE.OF ]60. <br /> TIF[ER t� ]s4. <br /> ❑ Yes ® No <br /> Name of CUPA,authorized agency, or LLA: 761. <br /> TITLE of CERT'I7FI►M� zss. I N/A '~ <br /> If certifier is other than CUPA)LIA check appropriate box below: 762 <br /> ADDRESS .s6. <br /> _ r+ ❑ a. Certified Industrial Hygienist(CIH) <br /> CITY C] b. Certified Safety Professional(CSP) <br /> ]n. I <br /> ❑ c. Certified Marine Chemist(CMC) <br /> I ❑ d. Registered I Environmental Health Specialist(REHS) <br /> PHONE " <br /> 58. <br /> 2 �Z ❑ e. Professional Engineer(PE)g b <br /> ❑ f. Class Q Registered Environmental Assessor <br /> DAq CERTIFICATION TIME ! g. Contractors'Stare Li cense Board licensed contractor(with hazardous <br /> substance removal certification) <br /> NK PRE, USLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> 67. i(I(yes,the wnk inlenor aonospheie shall be iectxckd wish a crambusoble gots iMicaror prior to work being contlucmtl on ute unk.) <br /> CERTIFIER'S r:\,IIK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: �YeS [2 No <br /> ]6a. <br /> I <br /> I A COQy Of tt CCrllflclle shad accompany the runs to the tecyclingthgosai Facility and be provided to the agency overseeing rank closure(t.e. CUPA or other authorized loran agency): <br /> ii <br /> (\\��"�At OE�e �15�m.anddte tank <br /> twit <br /> 0116100 <br /> \m\\`\\kP1�V yttPalwwaausdocs.org <br />