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0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />/erg <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Sneer PACIUTY NA 11w DDA -Debt aurlero M) 3 <br />FACILTIY IDN <br />^ <br />/ <br />1 <br />5�.�t3v,y gy,,J <br />15113 r. L%✓p Sr SyC len/ <br />TANK OWNER NAME 740 <br />/c/L/1C0/�, GEn//Jd'LL r,/„� rcrcr./✓ etc <br />TANK OWNER ADDRESS 741 <br />.z L 6 LF�1v<�Fa <br />TANK OWNER CITY �/ L tr %7G� STATElee /,,✓ 0', j 74711 ZIP CODE 7" <br />U. TANK CLOSURE INFORMATION <br />Tank m N <br />(Ama.amtlwnt wpia <br />Concmimmon of Flammable Vapor <br />lm Concentration of Oxygen <br />TANK <br />Dram it iveihm <br />tlxa unDnb) <br />TDP <br />Center <br />Bottom Top <br />Curter <br />Bottom <br />INTA OSP14ERE <br />1 �S a <�ss <br />74N <br />O ]Iota <br />]Kc /� ]Ile <br />/� A]b <br />/ 2. lnc <br />READINGS <br />5k16 <br />07N ]49. <br />]19e <br />]49e ]SOa <br />, <br />(� ]SOD <br />�, / 75ac <br />3 <�S6 /,751 <br />O l5L <br />752b <br />]5]e 753e <br />7536 <br />]5]c <br />M. CERTIFICATION <br />On examination of the tank. I certify the tank 6 visually free from product, sludge, scale (thin, flaky residual of tank contend), rinseate and debris. I further certify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATU CER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />14 <br />Certifier is a representative of the CUPA, authorized agency, 760 <br />g cy, or WA: <br />❑Yea XNo <br />OF R mitt) 751 <br />_ I // <br />� <br />Name oCCIIPA, authorized agency, or LIA: 761 <br />TIME OF CERTIFIER7M <br />V /i14C( <br />If certifier is other than COPA / LIA check a 763 <br />appropriate box below: <br />❑ a. Certified Industrial Hygienist (CUD <br />ADDRESS 755 <br />Al) 6o <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY 75 <br />/� G <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Enginew (PE) <br />PHONE 758 <br />r <br />❑ /L, Class 11 Registered Environments] Assessor <br />u9 <br />DATE <br />CERTIFICATION TUNE <br />P](g, Conbactors' State License Board licensed connector (with hazardous <br />111TTT <br />S-/q <br />/D' <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 761 <br />PrM Ne lank imivammmhercahaa be m4becked withacaebombkp hdknar priwwwwk hemtc,&wW 0 ibg u*) kLL Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764 <br />&,j /Op o� ��tad,✓/J <br />A copy of this cenificate aWll accompany the taek o the rcryclivg / dupoxl ficilih and W prcvidM m the CIIPA. Ifthav u ro COPA, isopia rhea W aubmined o 1W LIA and autharizcd <br />a e o owner /oPeratorofthetankMtemm removd Mafnetor and the MMcling / d' al facility. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />