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0 0 <br />UN ITIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Pa �f <br />I. FACILITY IDENTIFICATION <br />BUSINESS AME (S-- FACIUTYNA crDRA-Deftn Bun Nl 3 <br />FAcmn YID# <br />n <br />i <br />�'� <br />�T Ji /v.� T•C9A1 /7 Y <br />S 33 £. �i.✓/JS�1 57 S Tot',�7� <br />TANK OWNER NAME ]so <br />--T/" <br />TANK OWNER ADDRESS 741 <br />TANK OWNER CITY £ ]« STATE/-�ei,.,p/ ]« ZIP CODE 4f5OOs ]« <br />H. TANK CLOSURE INFORMATION <br />Tam ID A <br />'Alrh rddiymd eopr <br />Concentration of Flammable Vapor <br />Po <br />Concentration of Oxygen <br />TANK <br />of d,kpge fv mora rhoe <br />d.m UI <br />Top <br />Center Bottom <br />Top <br />Center <br />Bottom <br />INTERIOR <br />ATMOSPHERE <br />,S <br />O" i� <br />]aha <br />O ]say O ]ase <br />]a <br />r <br />ry 7M <br />]d]a <br />READINGS <br />r so� ]N <br />]19a <br />]d% © ]a9a <br />/ I D 5p. <br />/ / • V ],Spy <br />. O ]yk <br />752S <br />752b O ]37a <br />]53a <br />/ ]536 <br />f0 <br />/ 753t <br />(0 <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. 1 further certify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATU <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />l <br />Certifier is a representative of the CUPA, authorized agency, or LIA: ]6p <br />❑ Yes I?`No <br />0 CE,Rp (Rva) ]sr <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER ns <br />0-/;:v � � D/� � <br />/ <br />If certifier is other than CUPA / LIA check a ]6l <br />appropriate box below: <br />❑ a. Certified Industrial H Y&mist (CDI) <br />ADD S ]� <br />O �{ <br />`--� 0� <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY m <br />n <br />'✓ / r C7 S2- <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ eEngineer (PE) <br />Professional Engin(PE) <br />PHONE ]5a <br />�^ <br />Z T / <br />❑ L Class II Registered Environments] Assessor <br />g. Connacton'State License Board licensed contractor (with hazardous <br />fI <br />CERTIFICATION T[ME <br />J ` A <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS ]el <br />(Ify de utak idrenramOPhre dull be rechekenimth a candeabk ge irdinearp]ar rGaak being tudncesi nthe MI XYa ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACB,rrY, ETC: ]sa <br />6�4 <br />A copy ofthis cetifierte shall accompany the raakmrygsosaicid h Provd rhCUA. U,capiuWalM mhmiad b the LIA rad authorizeda ; ower / operator of the task systarc removal <br />fuiG . <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />