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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />I. FACILITY IDENTIFICATION <br />Ps of <br />BUSINESS NAME (Sue. u PAOLM nAalg or DBA -Doing Bulasu Ar) I <br />FACILITYID# <br />I <br />6 j7 COr7140 „9c. <br />TANK OWNER NAME <br />]b <br />TANK OWNER ADDRESS <br />].1 <br />do <br />'/ 7 <br />TANK OWNER CITY (�N ]sz STATE <br />]U <br />ZIP CODE '°s <br />H. TANK CLOSURE INFORMATION <br />L <br />iank ID # Concentration of Flammable V r <br />pnsch as6iuwW mpiu aPo <br />Concentration of Oxygen <br />TANK <br />ofaus pye fir mwe auto <br />tlssuNu) ToP Center Bottom <br />ToP <br />Center <br />Bottom <br />TERIOR <br />I 7a3 ]� ]Kb 1]� <br />READINGS - <br />1 -1 <br />. 1. rt <br />HI. CERTIFICATION <br />On examination of the tank, I certify the tank is visually flee from produtt, sludge, awle (thin, flaky residual of tank contents),�rinsmtc�Ifunher certify that <br />the information provided herein is true and accurate to the beat of my knowledge. <br />SIGNATURE OF CERTIFIFR <br />NAME OF CERTIFIER (meq <br />TITLE OF CERTIFIER ]ss <br />®!� <br />ADD S s6 <br />2^ ] <br />�_ 0 <br />CRY ]n <br />PHONE ]sa <br />® 3Z s Lf-/ <br />DATE / / ]i9 C'ERTIFXIZATIONi',')• }p <br />S7ATUS OR AFFB,IA7ION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />❑ Yes 19!�No <br />Name of CUPA, authorized agency, or LIA: <br />If certifier is other than CUPA / 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 (REHS) <br />❑ C. Professional Engineer (PE) <br />❑ f Class II Registered Environmental Assessor <br />Contractors' State License Board licensed contractor (with hazardous <br />substance removal certification) <br />I ANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />(Ilya, as uu,k inuior mwgbm"I h Me h aaiNacambuoble W Iedirav arly ro whhsmg soeAald on Ne nok) <br />Yes ❑ No <br />no l UrA, copies shall be bmined w <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />]60 <br />]61 <br />]63 <br />