Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br />ITAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />of <br />I. FACHM IDENTIFICATION <br />BUSINESS NAMEcsaarP�/Anc NAmv e.naA-Doing moomm) <br />FACILITYMN <br />' <br />� , p <br />TANK.OWNER NAME Tao <br />Jj-- Cd �Oixr✓ n%. <br />TANK OWNER ADDRESS <br />i <br />TANK OWNER CITY ��% 140 STATE _ rs) ZIP CODE al <br />II. TANK CLOSURE INFORMATION <br />Tank ID # <br />(Atmhaddiriard.0. <br />Concentration of Flammable Vapor Concentration of Oxygen <br />Top center Bottom Top Cerner Bottom <br />TAMC <br />ions �ta*o w <br />tN17aRIOlt <br />lasyb <br />I <br />>aw 7Mb 7050 7n. 7.m Neta <br />ATMOSPHERE <br />I..JJ <br />READINGS <br />Z 7" <br />74. 7a Naar 750. 150b 7500 <br />3 71 <br />75L nae 737. 75U 755b 755e <br />in. CERTIFICATION <br />On examination of the tank, I Certify the tank is viaonlly free from pmdw, sludge, scale (thin, flaky midual of fink contents), rinseate and debris. I further certify that <br />the information provided herein is nue and accurate to the hest of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the COPA, authorized agency, or LIA: 760 <br />❑ Yes <br />NAME OF CERTIFIER t"nu <br />z&lec ;�/ T P <br />.5Ao <br />Name of CUPA, authorized agmteY, or LIA: at <br />TITLE OF CERTIFIER 55 <br />®nl !t. />2 <br />if 0mdfier is other than CUPA / LIA Cheek appropriate baa below: Nati <br />❑ L Certified Industrial Hygieniat (CIH) <br />ADD <br />❑ Is. Certified Safety Professional (CSP) <br />❑ c. Certified Marine C15eatiat (CMC) <br />CITY 51 <br />❑ d. Registered Envimnmensal Health Specialist (RENS) <br />❑ e. Pmfcneional Engineer (PE) <br />- 75n <br />PHONE <br />® 32- <br />❑ f. Class 11 Registered Environmental Assessor - <br />Contractors' State Licensc Bond licensed Con=fm (with hazardom <br />7ss <br />DATE <br />TLFIF7R . 1' <br />substance removal eenification) <br />0 <br />0 <br />TAlqK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70 <br />rft eft oak M rxaerXW aeembanbkpiedlobpb 0 wk b0iganeeam5arhe roc) Yea ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY, ETC: lar <br />Ac,014 tr and beprovideda he CUPA If dtere q eo CIIPA e0pla obzll be snbmined b the UA and atlwriavl <br />esowett c�k <br />ami an/ <br />/ br of the Mar maIdisposal <br />d" nal ANi . <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />-> 1 <br />