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0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />z°r3 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (S.. s PAouTY NAML or DBA -Dan{Bmines N) <br />AH# <br />''I <br />7 <br />N3{L?�!115-i <br />fA <br />740 <br />TANKOWNERNAME <br />-�'e,ejZ,Jeo IA6 6t t1, tie :) SToe e7VA <br />741 <br />TANK OWNER ADDRESS - <br />ao { LjiJ 1/i 7G 300 <br />TANKOWNERCI[Y STATE /GL1,/ 1515 ZIP CODE r) ,) t� <br />H. TANK CLOSURE INFORMATION <br />Tank ID # <br />Concentration of Flammable able Vapor <br />Concentration of Oxygen <br />(Anaeh a tie tl eepiu <br />Top <br />Center <br />Bottom <br />Top Center <br />Bottom <br />TANK <br />ofdu pyefomveua <br />6aaeutotm <br />AI O IORE <br />4 <br />O 745 <br />7� <br />746E <br />]I& <br />.v ]IT )1]b2 <br />� 747CREADINGS <br />5 <br />0{/t 74 <br />74% <br />74% <br />/1 ]{9c <br />]34 20 75m <br />Lv 750, <br />O 75U <br />O 7316 <br />O 7$ <br />2— '753. LU ]3]E <br />V <br />.`1, 755c <br />IIL CERTIFICATION <br />On examination of the tank 1 certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseate and debris. I further certify that <br />the information provided herein is true and accurate to the bat of my knowledge <br />SIGNATURE OF CERT <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />on <br />760 <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />❑ Ya ANo <br />NAME R ) 151 <br />Name of CUPA, authorized agency, or LLA: 7m <br />ss <br />TITLE OF CERTIFIER <br />If cernifia is other than CUPA / LIA check appropriate box below: <br />❑ a. Certified Industrial Hygienist (CIM <br />-Ve76a <br />G, j i ertl - Qi iv e, <br />56 <br />ADDRESS <br />QX -3 S <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. CMified Marine Chemist (CMC) <br />CCTY 757 <br />G(Q Q ) �A, S <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />sa <br />PHONE <br />C C 11 C/ 61 ! <br />❑ f Class 11 Registered Environmental Assessor <br />g. Contractors' Slate License Board licensed contractor (with hazardous <br />739 <br />DATE <br />CERTIFICATION TIME <br />sub.3tanceremovalcerification) <br />< j:�'e rO t/ <br />76) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />(Ify¢da uN inaiw amua8ve rhall6e mcbeckedwiM tcomdaobNWiotictlo Picrmwak bevy caNatdmi6e tank) .�Ya ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY, ETC: 761 <br />�9FTf�C T21PC4L i2i�S�- T-�,�lrg c�rP�F� �v,.�o �f,,,rfo <br />�f/9�/-JAS �-✓O ,C34rr-c+il� i/��7'�( 12�,✓t£ /Z'A3�✓f' <br />/?.21 /C� ��£ �C 1J 2- 2-6 <br />A copy ofthis certill shall axornpany the utak to the recycling) disposal fmillry and be provided m the CUPA Ifthese is co CUPA, copies shall be submitted to the LIA zed authorised <br />a en ; owner I operator of the tisk s te'retvoval contractor and the cling/ disposal facilily. <br />UPCF (11/99) 39 Fortnerly DTSC 1249 (6/98) <br />