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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> or <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(S..e..rAcsury nAaSe e.oEA-o.Iq uuaA,) 5 FACILITY IDg 1 <br /> L 2 f/I r lnn�v..da✓• 'Gevra„ lo.,1a . n <br /> TANK OWNER NAMECZ1 ]w <br /> . t r a'- Gr�47(/e M/wsr. <br /> TANK OWNER ADDRESS 741 <br /> SS .S rCc f- ue'a'- G <br /> TANK OWNER CITY jor74a STATEC—/,F ]43 ZIP CODE ]a <br /> X701 / <br /> II. TANK CLOSURE INFORMATION <br /> Tank IDN Concentration of Flammable V r <br /> (Amen seidewt eopin apo Concentration of Oxygen <br /> orhhu peas ra mon Wso <br /> TANK skmm9o) Top Center Bottom Top Center Bonom <br /> DITERIOR I — ]45 Q ]4W O ]466 7416 747. <br /> ATMOSPtffRE � <br /> READINGS Z 74 74% 7496 74% ria. 750b 75ac <br /> 3 711 75L 7536 75U 756 Rlb 733. <br /> III. CERTIFICATION <br /> On examination of the tank,l certify the tank is visually free Isom product,sludge,scale(thin,Flaky residual of tank contents),rinseate and debris. I further certify,that <br /> the information provided herein is we and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER /J'/ / STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> d'/•`:l /L� Certifier is a representative ofthe CUPA,authorized ]60 <br /> D agency,m LEA: <br /> N <br /> NAME OF//CERTIFIER (r.0 / ❑ yes �'No <br /> ¢ <br /> `.Oyer 'raq�r a theme ofCUPA,authorized agency,or L1A: 761 <br /> TITLE OF CERTIFIER 755 <br /> IF&IF . is other than CUPA/LIA check appropriate Tat <br /> 7/a L het c7<r /ea !+0 yi�6:7f. UiDPriate box below:P <br /> ADDRESS 7w <br /> ❑ a. Certified Industrial Hygienist(CIH) <br /> Y/L U ❑ b. Certified Safety Professional(CSP) <br /> CRY 757 <br /> / l ❑ a Certified Marine Chemist(CMC) <br /> .(, CO r[Ys vq ❑ d. Registered Environmental Health Specialist(REBS) <br /> PHONE - - 75s <br /> ❑ C. Professional Engineer(PE) <br /> ❑ f Class D Registered Environmental Assusor <br /> 719 q(g. Contractors'Stene License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIMEq(.- <br /> removal certification) <br /> 9=1s- <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70 <br /> (Jres,dm unk innriorsonownensYll bsn�elm6 with seveilnWHM W iodirmr pdmm wmk briny msdn wtlwuak) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER DISPOSAL FACILITY,ETC. '764 <br /> Des�roy/Rrry'le Ste i/ ra h r Sana• Mc fc/ f/yr. f Pilriye� r� i <br /> Fa✓ 7'Ln /r WeJ fru) 74/.ar /yrs vP[Ie Trn.f 1�9'4 tre.sylos <br /> 's-good -O/-3l'✓crre'( <br /> A copy of this cesdgcsm shall accompany the tank in the recycling/disposal facility and be provided to the CUPA. If them is no COPA,copies shW M submihW m the laA avd suWori]ed <br /> sgoriMov, / star of the teak �remove)contractor and the Iinx/di sd facil' . <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />