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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />3.3 <br />I. FACILITY EDENTMCATION <br />BUSINESS NAME(sssas FA(3tATYNAAMwDeA-DabgBadns N) 5 <br />=M#©613:.,. <br />SvUJOL?F lU Qis'R.1c7 <br />N <br />TANKOWNER NAME <br />e ?Rico ,vim dc.✓, Ec(5rae)eM.J <br />711 <br />TANK OWNER ADDRESS <br />sol / LAN'o/i7c 300 <br />L r7lr 7a 7o ZIP CODE 711 <br />TANKOWNERCITY STATE /L ��� /S r� ) <br />IL TANK CLOSURE INFORMATION <br />Tank ID M <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />To P <br />Center Bottom <br />To P <br />Center <br />Bottom <br />TANK <br />°flhs paptaft) <br />daeeunb) <br />INTERIOR7 <br />ATMOSPHERE <br />Ol 5 � 7th <br />7th. <br />O 7Ne 746cG <br />d 7478 <br />W ' ^. 7.'!a <br />2 O los <br />READINGS <br />�r O / 7th <br />'J <br />7198 <br />74% O 7Nc <br />750, <br />Z6 754 <br />�a 750c <br />751 <br />751, <br />75A 75U <br />7558 <br />733b <br />751c <br />HL CERTIFICATION <br />On examination of the tank, l certify the tank is visually free from product, sludge, scale (thin, Flaky residual of tank contents), rinseste and debris. I Cunha certify that <br />the information Provided herein is me and accurate to the best of my knowledge. <br />SIGNATURE TIF <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or ILIA: 760 <br />❑ Yes ANo <br />N CFA <br />7% <br />Name of CUPA. authorized agency, or LLA: 761 <br />755 <br />T1T'LEOFCERTIFIER <br />-7 <br />CZ G / i tj/ZI f� Q/ .14 e <br />If certifieris other8rn CUPA / LIA check appropriate box below: 763 <br />❑ a. Certified Industrial Hygienist (CIH) <br />ADDRESS 756 <br />30X'J S <br />❑ b. Certified Safety Professional (CSF) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY 75/ <br />❑ d. Registered Envkommental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE 759 <br />O S <br />❑ E Class II Registered Envirome ental Assessor <br />S. Contractors' State License Board licensed connector (with hazardous <br />substance removal certification) <br />759 <br />DATE <br />CERTIFICATION TI9IE <br />_6L <br />L <br />6 <br />TANK PiEVIOIJSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />(IfYC se uiidaiersnu9bme ftUbe lrcadwirhaca°Wrobbguinl 9^aww bdrismhsmdmtbee ) Yes [3N. <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY, ETC: 7 W <br />4l, -r 74— IA<�r /2 I -u54 4 -id klr-v7'6D <br />%��'�90/N6S /3f�e7R£ //t'i�i( f?�,as� /,Z'�9/30✓� <br />-z6 <br />A copy ofthh eenifiese shall accompany the tank m the recycling/ disposal Odlity ad be provided to the CUPA. If throe is to CUPA, copies shall be submitted to the LIA and,uthorizod <br />a en , owner / o for of the tanks removal=b ,.dtheclion/diqwsdfkUity. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />