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0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Pa of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME(Same u FACILITY Ne or DBA—Dole, Bualuo M) 5 <br />FACILITY IDH <br />I <br />4410 S 09aV,, J ItF !4 ,I%' —Q lI 45 �- <br />TANK OWNER NAME 140 <br />E 2AC0 AC vE.J ESL J S7ocCTi7nJ <br />TANK OWNER ADDRESS 41 <br />a0/ 0 5f/.,225 300 <br />_ <br />TANK OWNER CITY %T.r: 142 STATE /��/� /54J ZIP CODE G ) ]s4 <br />H. TANK CLOSURE INFORMATION <br />Tank ID H <br />(Arch adBdmal.W. <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />ofmu a�fiauoewm <br />INTERIOR <br />I <br />745 <br />746a <br />7466 <br />7Mc <br />]4)a <br />7471, <br />747c <br />ATMOSPHERE <br />READINGS <br />Z <br />]48 <br />749. <br />749b <br />749e <br />75N <br />750b <br />750c <br />3 <br />751 <br />75U <br />7526 <br />752c <br />755. <br />7551, <br />753c <br />HI. 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 best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 0 <br />❑ Yes ANO <br />NAME OF CERTIFIER (Prim) 7M <br />71�J / /'c le AC <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER 755 <br />G/ i OfZI2. O/ /rJL, <br />If certifier is other than CUPA / LIA check appropriate box below: 762 <br />❑ a. Certified Industrial Hygiene[ (CIH) <br />ADDRESS 7% <br />[j <br />Cl b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY 757 <br />❑ d. Registered Environmental Health Specialist (KERS) <br />❑ e. Professional Engineer (PE) <br />PHONE 758 <br />Q�36 a S� <br />❑ f. Class II Registered Environmental Assessor <br />g. Contractors' State License Board licensed contractor (with hazardous <br />g. <br />759 <br />DATE <br />CERTIFICATION TIME <br />removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 168 <br />pfb the tank musior avttmphere shall te rechecked with acombumble gu indiutorpriot mwork beinecorducted of the tank) .&,Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: 764 <br />A eopY of tau certificate shall accompmy the teak to the recycling / disposal facility and be provided to the CUPA. If there is no CUPA, copies shall be submitted m the LIA and authorized <br />e en owner / o tm of the lank system; removal contractor and the res clip / disposal facility. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />