Laserfiche WebLink
0 9 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Po or <br />1. FACILITY IDENTIFICATION <br />BUSINESS NAME(5amen pAl7uTY r1AM6 mD9A-Doing gualnes N) 3 FACHdTY IDM 191 &1 :., q i <br />JST <br />SvlJ� c?e 10 —iv/s a,a7 G� fa✓Js <br />TANK OWNER NAME 740 <br />E ?,9C0 Ac >E.✓r Ecl 57oc crd.3t <br />TANK OWNER ADDRESS 741 <br />TANK OWNER CITY L r7;� STATE /LZ/,a/ /543 ZIP CODE6 J 741 <br />H. TANK CLOSURE INFORMATION <br />Tank IDM <br />(Awrh a5ditiwW apie <br />Concentration of Flammable Va Wr <br />Concentration of Oxygen <br />rANKams/uw�,gr <br />oftldapsae fa mue thsa <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />INNERIORE <br />ATMOS <br />.j <br />7 O �3u <br />]16. <br />]4m <br />]16e <br />]rn <br />)1'ro <br />)ac <br />READINGS <br />U GI ,f1a <br />D 6 7]51 <br />119a <br />i/ <br />)SL <br />7536 <br />75U <br />153. <br />7536 <br />753, <br />III. CERTIFICATION <br />On examination of the tank, l 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 herein is <br />provided urate the bes owledge. <br />SIGNATURE OF CERTIF <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />L <br />Certifier is a representative of the CUPA, authorized agency, 740 <br />reP g icy, or LIA: <br />❑Yea ANo <br />NAMEOF (qhu) 731 <br />/ <br />7N /yQ At <br />Name of CUPA, authorized agency, or LIA: ]Ii <br />TITLE OF CERTIFIER 755 <br />If certifier is other than CUPA / LIA check a 762/A1C, appropriate box below: <br />Cl a Certified Industrial Hygienist (CIH) <br />ADDRESS 735 <br />Q S <br />❑ b. Certified Safety Professional (CSP) <br />❑ e. Certified Marine Chemist (CMC) <br />CITY 757 <br />G) �A 5 <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ a Professional Engineer (PB) <br />PHONE 75s <br />C <br />Q �3 E 5 <br />❑ f Class ll Registered Environmental Assessor <br />g. Contractors' State License Board licensed contractor with hazardous <br />759 <br />DATE <br />CERTIFICATIO TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70 <br />pryer ds uNiirapi4ramnphee slullhmcheekrd wiN acanWmbuW indkalorpriww kbdO cnducbdm We tmk) .Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT DJSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY, ETC: 75r <br />/�//tSi /zC�iXDi /� �fFai[� Tr9nl.�S ewrrj; /ee'awe za /=�ccx! 6iLOu✓� <br />IN£ITfO �/Z;7 ') yi« . <br />A copy of this certificate shall accompany the tank to the recycling / disposal faoilily and he provided to the CUPA. If there u no CUPA, copies shall be submirud to the LIA and authorized <br />a en ; owner / o2mcor of the tank a tem, removal contractor, and the recycling / disposal futility. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />