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Mar , 19 , 2003 5 0F xNo 5566 P . 1 %C9 <br /> AX �J �, ed fle , <br /> UNWIEJ)PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFIC,A,TION <br /> Pae of <br /> I. FACILITY IDENTIFICATION <br /> BLI%NESS NAME(Sem=as FACILITY NAMe or DBA-Doiu@ Bustam As) 3. FACILITY IDS` pLL <br /> 1' <br /> Danny Benjamin <br /> TANK OWNER NAME <br /> Damy Benjamin <br /> TANK OWNER ADDRESS 7d1. <br /> 90 Mt. Oso Street <br /> TANK OWNER CITY Tracy 74� STATE CA 743. ZIP CODE 95376 744, <br /> XT. TANK CLOSURE XNFORMATTON <br /> Tank ID# Concentration of Flanrlmable vapor Concentration of Oxygen <br /> {Attach additioaai ropier <br /> Ak/' of ms pate for more than Top Center Bottom Top Center Bottom <br /> Wee Lwksl <br /> I If71t 1 746a. 746b. 744c. 747x. 747D, 747c, <br /> ATMOSPHERE V/ <br /> READINGS 2 7aq. 749x. 74'9b. 7d94. 73 &, 73r7b, 753c. <br /> 75 A, 732b, 7524. 753a. 753b. 7,y3c, <br /> XIX. CERTIFICATION <br /> on examination of the tank,I certify the tank is visually free frorn product, sludge,state(thin,flaky residual of tank contents),rinseate and debris, I further certify <br /> that nfbrmation provided herein is true and accurate to the best of my knowledge. <br /> XT <br /> F CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA; 760. <br /> 7j4. 0Ye6 9 N <br /> Wrinc} 761. <br /> �fkEL,�R <br /> Owry Name of CUPA„authorizEd agency,or LIA: <br /> TITLE.OF CERTIFIER 733, NIA <br /> President, George W. Lowry, Inc- If certifier is other than CUPA I LIA check appropriate box below: 742' <br /> ADDRESS '756. [j a. Certified Industrial Hygienist(CW) <br /> POP Box 176 ❑ b. Certified Safety Professional(CSP) <br /> CITY 757. ❑ c. Certified Marine Chemist(CMC) <br /> Salida d, Registered Environmental Health Speciiilist(REHS) <br /> 755. <br /> PHONE ❑ a- Professional Engineer(PE) <br /> 209-545-0791 ❑ €, Class H Registered Environmental Assessor <br /> 73 g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIMEg. <br /> removal certification) <br /> 2.13.2003 t <br /> 763. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTJgLt MATERIALS <br /> {[ryes,the tank totertor almoephom$hall ba re-4heckod with a combusaibie gas ipacator prior to worse being conducted oa the tnir.) Z "Ices ❑ No <br /> TIFIER'S T?,,NK.MANAGENI.ENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY;ETC: 744. <br /> This tank is for scraping arld no other use is to mandated_ Check tank interior atmsophere with combustible gas indicator before <br /> working on tank, <br /> o t cc urlya irgha to a l)ngld l� and b provided to the agency ovcrmeing tank cSssure(t CUPA or other autharizod local agenry); <br /> the owner an t tjj a tank system;and the tank mmova0 contractor. <br /> 0— mncmn <br />