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9 <br />0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />h or <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Sameu FACILITY NAME m DBA-uomasusinev.4r) 3 FACILITY ID# t <br />S,G3'U . <br />TANK OWNER NAME 740 <br />,E WO /Jc 5ree'emA <br />TANK OWNER ADDRESS 741 <br />sol iLTJ' >G 3vo <br />_ <br />TANK OWNER CITY 742 STATE Zip CODE() 794 <br />IL TANK CLOSURE INFORMATION <br />Tank ID # <br />addnimul copie <br />Concentration of Flammable Vapor <br />aPo Concentration of Oxygen <br />TANK <br />orthothu three ran more Nan <br />three nut) <br />Top Center Bottom Top Center Bottom <br />INTERIOR.' <br />ATMOSPBERe <br />]45 <br />]46a 746b 746e ]4]a ]4]b ]4]c <br />READINGS51 <br />TO <br />749a 14" 749e 75th 7506 750c <br />I 751 <br />75U ]Srb --f52-e— 753a 753b 753c <br />III. CERTIFICATION <br />On examination of the tank I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rimeate 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, J60 <br />g cy, or LIA: <br />❑ Yu ANo <br />NAME OF CERTIFIER (Prize) 754 <br />7�J -7-110 /Z ! C <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OF CERTIFIER 755 <br />If certifier is other than CUPA / LD1 check a ro 762 <br />pp prate box below: <br />❑ a Certified Industrial Hygienist (CIH) <br />ADDRESS ]w <br />Q /j' <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY ]s] <br />i <br />at/ <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE ]5e <br />'71© S' �j <br />❑ f. Class II Registered Environments] Assessor <br />g. Contractors' State License Board licensed contractor with hazardous <br />g. <br />]s9 <br />DATE <br />CERTIFICATION TIME <br />removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70 <br />afy the an* inurieraomplwe anal bere-chocked with•camb kae gas idiptmprior towwk being conducted on the UNk) 4!41YeS C]No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: ]u <br />A copy ofihh cenifieate shall accompmy the tank to the recycling/ disposal facility and be provided to the CUPA. If there h uo NPA, copies shall be submitted to the LIA and authorized <br />e en owner / o retm ofthe tuck system; removal momactor and the recycling / disposed facility. - <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />