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0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />P �of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME(same n PACIUTY NAME or DBA -Mail R.I.. M) 3 <br />FACILITY IDN <br />164160�-)Z <br />sAa Zi,J ('ke /0 .,6 -vis rt/ o y <br />. <br />TANK OWNER NAME 1qp <br />E ACO Ae- 6t.t1 Eel S7oc cTd,J <br />TANK OWNER ADDRESS 741 <br />a o i 0610 LAN �,/1>� 300 <br />_ <br />TANKOWNERCITY %%G 743 STATE/Lel ,e143 ZIPCODEG ) 741 <br />J <br />H. TANK CLOSURE INFORMATION <br />Tank ID N <br />(Attach additioal copes <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />Drum itee,fWA.))drat <br />INTERIOR/ <br />ATMOSPHERE <br />I <br />0jI`'..us <br />746a <br />latb <br />0 <br />746c <br />7/7a <br />Z . � <br />J -1<]b <br />/rj- <br />2, 531h <br />12, <br />READINGS <br />2 <br />O11a (/'l4 <br />74% <br />2491 <br />^ 749c <br />L <br />750a <br />1506 <br />150e <br />i` <br />` jo � 751 <br />D 75U <br />O 1521 <br />7 15k <br />-153a <br />7536 <br />83c <br />HI. CERTIFICATION <br />On examination of the tank, I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rimeate and debris. I further certify that <br />the information provided here' and accurate to the best of my knowledge. <br />SIGNATURE OF <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 'ro <br />C] Y" ANo <br />N F RTIFTE (Prim) '� <br />NQ �Z <br />Name of CUPA, authorized agency, or LIA: '61 <br />TITLE OF CERTIFIER 7M <br />ICcertifier is other than CUPA /LIA check appropriate box below: 62 <br />❑ a. Certified Industrial Hygienist (CDH) <br />ADDRESS 7% <br />?b LQ S <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY 757 <br />❑ d. Registered Environmental Health Specialist (REBS) <br />❑ e. Professional Engineer (PE) <br />PHONE 79 <br />Ocl�3 6 S <br />❑ f Class 11 Registered Environmental Assessor <br />g. Contractors' State License Board licensed contractor (with hazardous <br />159 <br />DATE <br />CERTIFICATION TIME <br />- <br />substance removal certification) <br />r <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br />(If ya,de unit incier amtorplwre doll be rechecked with a combuoble an indicator prior to wart beinyco txim die unk) . Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: 7u <br />Fi2S7�iE�lDi..� �ro�(� T.JCS Cd/£-[� /7��rovf0r'�Co�7 6�1o✓✓!J <br />A copy of this certificate shall accompany the tank to the recycling / dispoal facility and be provided to the CUPA If there is no CUPA, copies shall be submitted to the LIA and authorized <br />a en ; owner / operator of the tank systene removal contactor and the recycling / disposal facility. <br />UPCF (17/99) 39 Formerly DTSC 1249 (6/98) <br />