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0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />2,f <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Sana as FACILITY NAIHR er DBA -Dong aeslnm As) J 1 FACILITY ID# ii <br />G> 5-33 6. �,✓os rr. sr� o <br />TANK OWNER NAME 740 <br />E ?ACO .jc 6iiid zL 57aceMA <br />TANK OWNER ADDRESS 741 <br />v; T� 300 <br />_ <br />TANK OWNER CITY Z %T!� 7u STATE/r)o ZIPCODE� 714 <br />H. TANK CLOSURE INFORMATION <br />Tank ID # <br />(Auad, udisany es <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />TANK <br />ofada Nge for mme nun <br />aa«takw) <br />Top <br />Center <br />Bottom <br />'Fop <br />Center <br />Bottom <br />INTERIORd{ <br />ATMOSPHERE <br />4 <br />t}IS <br />QI ' f7 <br />746a <br />7466 <br />]/sc <br />]I]1 <br />f <br />]alb <br />]a]c <br />READINGS <br />{,jAa <br />r <br />O 719a <br />]4% <br />- O 719ca <br />eo1 <br />-J 750c <br />G V114 �•J <br />b <br />753a733b <br />a4a75Jc <br />III. CERTIFICATION <br />On examination of the tank, I 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 he and accurate to the best of my knowledge. <br />SIGNATURE OF <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />/ <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 760 <br />❑ Yes ANO <br />NAME RTD7 (Prim) <br />T Q /Z �C <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER 755 <br />22 ef C- 70 I i �rZl !i; tJ/ /A1C, <br />[f certifier is other than CUPA /LIA check appropre[e box below: 7u <br />❑ a Certified Industrial Hygienist (CIH) <br />ADDRESS 755 <br />r <br />Q j 7 <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemie (CMC) <br />CITY 7n <br />i <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE 736 <br />Q c S <br />❑ f. Class 11 Registered Environmental Assessor <br />g. Contractors' State License Board licensed contractor (with hazardous <br />739 <br />DATE <br />CERTIFICATION TIME <br />7-q-/ 11)k <br />p, <br />substance removal certification) <br />'-7/ <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70 <br />(Irm daunt imnier amiuoart Iber heckMman a canbwbblegas indiumr pion b wwk being wtlrcudm We tuh.) Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY, ETC: 754 <br />f�/lS7` L2E/P�/••��Q�Fai� Tif.�7/C� 4/£1C� /�s+10U£/%/—/Cdn'j C�lvr�.f�/J <br />A copy of this certificate shall accompany the tank to the recycling / disposal facility and be provided he the CUPA. If then is an, CUPA, copies shall be submitted n the LIA and authorized <br />a en ;owner / operet. of the tank system, removal contractor, and the recycling / dirposell facility. <br />UPCF (12/99) 39 Forinerly DTSC 1249 (6/98) <br />