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0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />r, ar3 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME(5,mau PAaury nANgmoeA-Doing emloea A.) 3 <br />1 FACILITYIDf/ <br />i <br />l <br />TANK OWNER NAME 710 <br />TANK OWNER ADDRESS 711 <br />2 0l 5-61/7r300 <br />TANK OWNER CITY lis I STATE/Z,/j,�0/,$ Je3 Z3PCODE �o CJ'/ ]a <br />H. TANK CLOSURE INFORMATION <br />Tannk q <br />Tank D I <br />(Am TaD w.0.Wr <br />Concentration of Flammable Va <br />Concentration of Oxygen <br />TANK <br />ofihiapagefernaaedaut <br />dure nNu) <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />INTERIOR <br />ATMOSPHERE <br />]u <br />'7 ais� 3 <br />716. <br />D <br />O ]166 <br />D 7ue <br />/7a <br />/� ---7-- <br />/ A'h <br />71h <br />READINGS <br />/ ]W <br />O Aga <br />/-5 M%O <br />]/9e <br />]Sh <br />u06 <br />)SOc <br />75D <br />]S]a <br />]53a <br />7536 <br />753c <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), mueate and debris. 1 further certify that <br />the information provided herein is true and accurate to the best of my knowledge <br />ATURE OF HER <br />LCertifictill <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />L <br />R representative of the CUPA, authorized agency, or LIA: 7W <br />,�,/� <br />❑ Ya vivo <br />NAn CERTI R (Pkv) ` 751 <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER 755 <br />,/ <br />ClC9 ` J //y ; Q/?P /e v <br />If certifier is othtt than CUPA / LIA check appropriate box below: 70 <br />❑ a Certified Industrial Hygienist (GIFT) <br />ADDRESS 756 <br />�/ C <br />0 -10)6 J <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY 757 <br />/N D cf-/ <br />❑ d. Registered Environmental Health Specialist (REHS) <br />Professional Engineer (PE) <br />PHONE 753 <br />C,Ele. <br />/ Z '5- t r <br />❑ f. Class lI Registered Environmental Assessor <br />Contractors State License Board licensed contractor (with hazardous <br />DATE s <br />CERTIFICATION TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 761 <br />Pfy Ne sole Mbaiarwwlilae shall be rb he withaccanNuabtegasa"Ostrpdet w wvk bdngeoai¢Yd an weIwk) Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY, ETC: 761 <br />1I£'/570/.�fMOt/fD/�/N/� 5.f c2n/ <br />pit G�l�✓�� <br />A copy of this eMificam shall accompany the tank to the recycling f disposal facility and be provided m the CUPA. Itaere u m Ct3PA, copies shW be submitted a We LIA and authorized <br />agency; owner / o ar of the tank systerea removal contractor and the rccycling / disposal facility. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />