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0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />anneene <br />PW /of -2— <br />I. <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAM (a.... FAauTv N,usu ar tim- was e,uleen A.) J <br />1 FACILITY ED# <br />% <br />I <br />so ✓ 171st / <br />r/533 e. L�„rgs 17 SY T <br />TANK OWNER NAME 710 <br />� iJE. SE,k10ELC �J.J SloCKIi..1 < <o <br />TANK OWNER ADDRESS 741 <br />3-z0/ 0U45eEA)l-'le4lol Sv/rf .300 <br />TANK OWNER CITY T%L I STATE/cc/nf0/-ea` I ZIP CODE 7" <br />IL TANK CLOSURE INFORMATION <br />Tank ID N <br />(Attach aaditimY cape <br />Concentration of Flammable Vapor Concentration of Ox en <br />a(10 y6 <br />TANK <br />oflhkprgefarmethan <br />decenryw) <br />Top <br />Center <br />Bottom Top <br />Center <br />Bottom <br />INTERIOR <br />ATMOSPHERE <br />1 <br />D/�SO/ Ju <br />7.N <br />7461,O <br />7405c ]e <br />READBiGS <br />2 <br />C <br />/SU/�]4 <br />D�/w751 <br />74% <br />Q 749b <br />Q 7/9e r -s_ D 75oe <br />`� <br />Q 7!5(b�+ <br />O 750c <br />7 <br />J <br />75L <br />- 73a <br />O 757e ]SL <br />]316 <br />753a <br />M. CERTIFICATION <br />On examination of the tank. I cetify, the tank is visually free from product sludge, scale (thin, flaky residual of tank contents), rin leate and debt's. I further certify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATU CER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />a Z <br />Certifier is a representative of the CUPA, authorized agency, 760 <br />g cy, or LU: <br />❑Yea {p No <br />CERTIFIER 7M <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER 755 <br />/� 12!'� Q/� /wi <br />7u <br />If artifia is other thins CUPA / LN check appropriate box below: <br />Cl a. Certified Industrial Hygienist (CIH) <br />ADDRESS 7M <br />6 15- > <br />❑ b. Certified Safety Professional (CSP) <br />❑ a Certified Marine Chemist (CMG <br />CITY 7n <br />�^ c .4 <br />t.. <br />1 / C <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE 758 <br />LV'/ 3 Z 9 <br />❑ E Class 11 Registered Environmental Assessor <br />g. Contractors' State Liceme Board licensed contractor with hazardols <br />759 <br />DATE <br />CERTIFICATION TUSE <br />-7 -� <br />substance removal certification) <br />• o0 <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 761 <br />(If yes. 0. mh ineioremuplaetlWl ben diecked with asanbuan'bleP indiatortriorto wortberyeoMuSNm dic lade) Yp ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: ]u <br />iZEI-9eo/Ag- '8'Ee q � 'T/rr aeS Lc%/(v-- ID 65 TzoyE> <br />RE,40/.o 6 7.' oO&S T/2JyE> %'3V may,-/ 3 - os—,' <br />A copy ofuhu certifceas shell accompany the nick to the recycling / disposal facility end be provided in the CUPA. If there is no COPA, copies .hell be aubmided to the LIA and authorizcd <br />.1tricy0owns / operaparof the tank system ratooval contractor and the recycling/ disposal facility. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />