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0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM - <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME(samr r PAQUTV NAMR err DBA—Doteg 5u N) 3 <br />FACILITY IDM <br />Q ^ <br />t <br />TANK OWNER NAME ]<o <br />T (fC2 CZEnAFI/eSj:�;�x7 <br />TANK OWNER ADDRESS 741 <br />j <br />OGJ G Lg V/ W / 00 <br />TANK OWNER CITY STATE�CI/,Vp U ZIP CODE C?/ ]w <br />II. TANK CLOSURE INFORMATION <br />Tank ID M Concentration of <br />Flammable VaporIA <br />Concentration of Oxygen <br />TANK <br />.ra.dfmdun <br />uneum.) Top Center Bottom <br />-ii <br />Top <br />Center <br />Bottom <br />R <br />INTERIO1.0 <br />ATMOSPHERE <br />- ]ss ]/6a <br />]cab <br />rage <br />u ]na <br />.O <br />le'A <br />s]c <br />READINGS/ <br />�// ``/A� O NPn <br />7 D/�]s/1 <br />O ]d9b <br />0k <br />]sa <br />, ]sob <br />' )3oc <br />3 ]SL <br />I <br />L <br />753b <br />)s)a <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 c dify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF R <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />a <br />Certifier is a representative of the CUPA, authorized agency, '60 <br />g ry, or LIA: <br />Cl Yes 40(No <br />NAME (Prhd) 366 <br />f <br />111j10/rP� <br />Name of CUPA, authorized agency, or LIA: 761 <br />TIME OF CERTIFIER]ss <br />t' j C /C /,tJC. <br />If certifier is other than CUPA / LIA check appropriate box below: rb] <br />❑ a. Certified Industrial Hygienist (GIFT) <br />ADDRESS ]ser <br />19v 36Ki <br />3 <br />❑ b. Certified Safety Professional (CSP) <br />❑ a Certified Marine Chemist (CMC) <br />CITY ]n <br />/ �-,t1 per' <br />ei) 1 u r • / 7� � � <br />❑ d. Registered Enviromnental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE ]ser <br />r <br />Z 7 (7 <br />❑ L Class II Registered Enviromnenml Assessor <br />®.B. Contractors' State License Board licensed contractor (with hazardous <br />DATE 159 <br />CERTIFICATION TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS lel <br />(ItM to mtk iuerior mm muoa be r"wkdmta aecmbwalbW M adiaurpim m work bdsacmdawl at We tdc) Yea ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACR.ITY, ETC: tw <br />raXs 4-1E.zsL v,-r-'srrtoyZL) <br />:'ial 3 -,V --14t <br />A copy of this comficate shall accompany the tank to the recycling/ disposal facility and be pmvidd in the CUPA. If Wen is no CUPA, copies shall besubmined n We LIA and aulhorizd <br />s cn ; owner / o for of We tanks tem• remowl mntia . and We cIm / d' al fwiu . <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />