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02/08/2007 12:13 FAX VALERO ENERGY IM 002/002 <br />UNIFIED PROGRANJ CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Pa � or <br />1. FACILITY IDENTIFICATION <br />I <br />BUSINE(SS�N,AgM�E(s/.na.•reen.m nA.nr. o.OUA-bole aml„•„^sl ] FACILITY IDN �.', <br />V//Ci,Fi� uo <br />TANK OWNER NAME <br />�G- �FFitii�vG Go,H„v.4>v�_ rel <br />TANK OWNER ADDRESS <br />n <br />v �� <br />TANK OWNER CRY STATE ve ZIP CODE7�u�-Q <br />IL TANK CLOSURE INFORMATION <br />Tank ID N <br />Coocent adon of Flommable Vapor <br />Concentration of Oxygen <br />(Aw r li—; P^P- <br />onmsp•a. f=.max �Mn <br />T� Center Bunom <br />TOP Centar <br />Bottom <br />TANK <br />INTERIOR <br />Ihrwl+nkd <br />1 us <br />L <br />- )I/ ]<m / )ane o r+r� <br />N e <br />11]a <br />7 <br />Pnv <br />0 <br />ISk <br />ATMOSPHERE <br />READINGS <br />1a6 <br />- 5avb H9c <br />74% 3 / <br />+ HW ]Sae <br />L� <br />2 <br />151 <br />ISL ]3^b ]5^c <br />tSH )alE <br />t3h <br />7 <br />111. CERTIFICATION <br />On examination of the tank, I certify the rank is visually free from predum, sludge, scale (thio, risky residual .P rank co,wOO), rinseaw end debris. 1 further certify rhes <br />the information provided herein is vue and accurate w the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />70 <br />Certifier is a reprusenutive of the CUPA, authariud agency.or LIA <br />[3 Yea [No <br />rst <br />NAIVE Of CERTIFI (Prion <br />rat <br />Name ofCUPA, authorised agency, or LIA: <br />TITLE OF CERTIFIER <br />i <br />]at' <br />j If c,nif er is arher than NPA I LIA check appropriate be. beta.; <br />i ❑ a. Certified indusrrial Hygienist (CIH) <br />—� ]>a <br />ADDRESS <br />S� <br />[1b. Ccrtifred Safety Professional (CSP) <br />6� >s] <br />I <br />❑ c. CoRificd Marine Chemist (CMC) 1 <br />CITY <br />/-,� <br />I (] d. Registered Em'iranmental Fleald]specialist (REHS) <br />S14� ✓ i i -r <br />w C2, 4 _fr_�_� p q <br />❑ e. Professional Engineer (PE) <br />PHONE <br />1 { <br />r Class 11 Registered Enviromnentel Assesor <br />Contractors' State License Board licensed contractor (with herardous <br />DATE <br />CERTIFICATION TIME <br />s.bsunce removal certification) <br />/,z.- 6- O6� <br />%/ d O A zIA. <br />of <br />TANK PREVIOUSLV HELD FLAMMABLE OR COMBUST{BLE MATERL%LS <br />i <br />llfya,,hxbl,n.ror+bruepkexiNplrcxalecarC alma wmEmeole Wlrak+�or Ab.;..e'omdoued en@eaN.l <br />CEATIFfER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FAC[LIT1•, ETC: <br />C GCA CON /�'1 TFlNkS <br />r/�NJL D/SP�SAL C�IC)G/7y Sf'IAGe- r/( <br />%N61t7 10116A- TO O✓GivG /}�7/c�ON <br />Of .rfy �k5 (��R /srasFtL /�E�Hl ri fff�v/�E.4'0 v7 <br />virl�� <br />i—..__.—....:a:.,o-..xnu e..nmoanv the wok fo rhe rteyeliny)Jbpovl auliry +ndE: CrorideJ to IFZ CUPA. IYlhere is no CUPA..apios shall tw submiuealolMLlA anJ uo�Eo:iud <br />I„ -op f I he 1,ink eneval ceanc+e avd do mcvcline) Jleroem e<n,rc. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6198) <br />