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0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />P of eZ <br />L FACILITY IDENTIFICATION <br />BUSINESS NAME C-- u PAaury NAM or DbA-Dong Rtoe M) 3 <br />FACILITY IIBI <br />/.J1 /OJAL 517/�fST/cT <br />/S"3 Li.✓ S o ori✓ <br />TANK OWNER NAME lea <br />%�R� c ,a9c. s piEtC te/.J S7oceE� l�L <br />TANK OWNER ADDRESS 741 <br />10/ <br />TANKOWNERCIY CJI C/» `� STATE LLIN©I�4ZIP CODE fp Om 9 ]« <br />H. TANK CLOSURE INFORMATION <br />IAm TankID <br />oPie <br />TANK <br />ofdusp.aeformmethm <br />d.acmdo) Top Center <br />Bottom Top <br />Center <br />Bottom <br />MTE91OR <br />ATMOSPHERE <br />� 4 7Ma ]eats <br />I / Q <br />]4e 7e'/. <br />Q <br />� 7476 <br />� � 7e7c <br />READINGS <br />2 O/ `]4 O 74% ]I% <br />O ]e9e e / ]50. <br />/ ]fab <br />/ ]Sac <br />3 ��5�/('7SI TSLO ]Sm <br />D ]S]c 75U <br />7536 <br />]Slc <br />HL 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 certify that <br />the information provided herein is true and accurate to the bat of my knowledge. <br />SIGN OF R <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the COPA, authorized agency, or LIA: 760 <br />❑ Yea No <br />XAMI(OF CFRR (Palm) 754 <br />71:,;%%% /�/01CA <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER 755 <br />—� <br />i� f C . <br />If ceRifie is atha than CUPA / LIA check appropriate box below: ler <br />[3a. Certified Industrial Hygienist (Clfi) <br />ADDRESS 7% <br />1-Q,5ox 3 <br />❑ b. Certified Safety Professional (CSP) <br />❑ a Certified Marine Chemist (CMC) <br />CITY 75 <br />/ (5-1 • 5 <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE 79 <br />1p 3 Z ] � tip-/ <br />❑ L Class 11 Registered Environmental Assmsor <br />g. Contractors' State License Board licensed contractor with hazardous <br />g.( <br />759 <br />DATE <br />CERTIFICATION TIME <br />- -/ <br />�',3p <br />removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 761 <br />Ofyra des twa iad(raaraphee shall W rschck-d Mth•canbesabte an o kg prior to workbeigoosduemd on the Wc) Ya ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: Tse <br />G�tsT �zFAa/�� /Co2 o 4te <br />A copy of this certificate LWI accompany the tack m the recycling / dispn4l facility and be provided to the CDPA If then is no COPA, Copies &.11 be avbmimd to the LIA and authorized <br />.Rencimowner lopeamerofthe tanksystem- removal rontactor and the Im / d' facility. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />