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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />T <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME(a— ar PAaury Nmer w DBA-owns amuses An 3 <br />FACILITY IDN JFW - <br />1 <br />l or7CT�rnfs>J/s�.Cic7' <br />L�.33 cam. Li.✓9s�f sX S7'oc�7.✓ <br />TANK OWNER NAME 740 <br />TANK OWNER ADDRESS 741 <br />LO OLD6 !/l £c✓ v i 7AC 3120 <br />TANK OWNERCITY 7n STATE Ge/�V /S7U Ze CODE ���5 7u <br />H. TANK CLOSURE INFORMATION <br />Tank IDN <br />ID eoP4a <br />(Ara Tak <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />Y6 <br />TANK <br />ofrhia pge rarmse tlun <br />6.ee mun) <br />Top Center Bottom <br />Top Center <br />Bottom <br />ERI <br />INTERIOR <br />Af <br />0'6 '9]l3 <br />f 7M. O ],bb Q ]I& <br />• r./7ch ;, �/7c'A <br />a 1i6/ <br />/• ej 747c <br />(i <br />bfj <br />READINGS <br />D 31 <br />27 011:79'13 <br />0 74% Q 7496 O ]Lae <br />750. �L 75ab <br />(% 754 <br />T/� <br />751 <br />O <br />]SL O 753b Q ]3]e <br />2 ]S]. 753b <br />_3 7534 <br />UL CERTIFICATION <br />On examination of the tank. I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinsate and debris. I further certify that <br />the information provided herein is nue and accurate to the bat of my knowledge. <br />SIGN RTI <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a repagency, resrntative of the CUPA, authorized or LIA: 760 <br />❑ Year �No <br />OF CER R 7 <br />.((R/� e �£ <br />Nunes of CUPA. authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER 735 <br />//( Q •'� � - � ,�' ,��, <br />If certifier is other than CUPA /LIA check appropriate box below: 763 <br />❑ a. Certified Industrial H ygimirt (CDFI) <br />ADDRESS 7% <br />' <br />O .3 S <br />❑ It. Certified Satiety Professional (CSP) <br />❑ c. CMified Marine Chemist (CMC) <br />CITY 757 <br />t�/1 ^ <br />4W Ol / Z r-�� <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE ss <br />4-P 93 2 <br />❑ L Class 11 Registered Enviromnrnml Assessor <br />�g, Contractors' State License Board licensed contractor (with hazardous <br />g. <br />759 <br />DATE <br />CERTIFICATION <br />TIME <br />removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70 <br />GfYs.lhe wk611visamrsplee shYl6r mKheeked aitll aeanMaablepiNkaorpismwok bemgeotllatedm tlsmlt) AYa ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: 761 <br />A copy of Zhu certificW "I axompmy the tank to the recycling/ dispoW facility and be provided to the CUPA. Ifthm la no CUPA. copies shall be wbmined to the LIA and authorized <br />a en • owner/ openatrofthe tank systeng remonl contracme and the recycling / d' sal facility. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />