Laserfiche WebLink
0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Ira, Zof 2— <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME tS. as PAaury ri M or maA-Danz jsush nm) 1 <br />FACILITY IDM 1 <br />1 <br />S f!i Dior i/! srT T;C <br />/533 Cel-0054Zsy sTc,f a� <br />TANK OWNER NAME 7a <br />k,,6f 1,4--. G i Oc.E ,v G <br />TANK OWNER ADDRESS 741 <br />,73 2 0 0,/ v 6426.0 //iTE O <br />TANK OWNER CITY /.0 77� STATF/ee/,JOIS7u CODE 71 <br />H. TANK CLOSURE INFORMATION <br />Tank IDN <br />tAmeb dye„ i Iia <br />Concentration of Flammable Vapor <br />PD Concentration of Oxygen <br />TTANKa.ae <br />otih'a ater sdw <br />adn) <br />Top <br />Center <br />Bottom Top <br />Curter <br />Bottom <br />INTERIOR <br />ATMOSPHERE <br />763 <br />/ <br />7Ka <br />74%O <br />O <br />7abc ]fh <br />, <br />]67b <br />r <br />747c <br />READINGS <br />/-1' <br />Of7////5�/ <br />7�P <br />O1b <br />75 <br />750r$ <br />S <br />31 <br />7 C <br />]SLQ <br />71 <br />DacS�,0 <br />�SA70 <br />7516 <br />V <br />753, <br />HL CERTIFICATION <br />On examination of the tank, I certify the tank is visually free from pmduct, sludge, scale (thin, flaky residual of tank cpntents), rinseate and debris. I further certify that <br />the information provided herein is true and accurate to the beat of my knowledge. <br />SIGNATU CER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the COPA, authorized agency, or LIA: 760 <br />❑ Yes JKNo <br />cwm OF — ' > <br />�It ! <br />NQ!{�� Name of CUPA, authorized agency, or LIA: 76i <br />TITLE OF CERTIFIER 753 <br />If certifier is other data CUPA / LIA check appropriate box below: 70 <br />❑ s. CMified Industrial H <br />Hygienist (CIH) <br />ADDRESS 736 <br />��,. / LJ <br />GX//((J ) <br />❑ b. Certified Safety Professional(CSP) <br />❑ c. CMifiedMerine Chemist (CMC) <br />CITY7n <br />��/ C ' J . / <br />'J /J p� 7/ <br />❑ d. Registered Environmental Health Specialist(REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE 751 <br />`L <br />2 d Z 5 �T �/ <br />❑ f Class Il Regiatared Environmental Assessor <br />g. Contractors' Stets License Board licensed contractor (with hazardous <br />73s <br />DATE <br />CERTIFICATION TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 761 <br />(um do WA 44eriammP6ae shalt be rechckd tdtharessbbaalbw indiwwaior n role bevy aadutted on de Wk) Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: 7M <br />DEALER, <br />>9�,ts ,ifs>r�y�v <br />/2f�9/-� f �%Do /9^� iiE'siro y��l % •'moo � � 3-05 = �5` <br />A copy orthh cvrifxate shall socaapnny the uok a the recycling / disposal facility sod be provided to the CUPA. Ifthere is no COPA, Copia shall be submitted to the LIA and authorized <br />m <br />a cn owna/ operstorofthe lank s to • removal contractor and the clies/ disposal liscifity, <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />