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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> F77 HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pg'e i of <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME <br /> E((Same as 1FACWTY NAME or DBA—Doing Busing As) 3 FACILITY ID# t <br /> TANK O ER NAME 740: <br /> e aC\-rD LA. V,V L <br /> TANK O ADDRESS 741 <br /> W . <br /> TANK OWNER CITY743. <br /> STATE ZIP CODE 744. <br /> II TANK CLOSURE INFORMATION <br /> Tank ID# <br /> (xh (Aftch additional copies Concentration of Flammable Vapor Concentration of Oxygen <br /> of this page for more than <br /> TANK tbreetanks) Top Center Bottom Top Center Bottom <br /> INTERIOR c7L4�. �y..746a 7466. 746c y 747a 1 7476, y 747n <br /> TMOSPHERE l 3 '�SIls3J / ( [� <br /> v t <br /> READINGS 2 748. 749a 7496, 749c 750a. 7506. r� 750c <br /> 8- 2 D.C7 Zo : . <br /> 751. 152a: 7526. �752e- -��y 753a. 753b. 753c <br /> SC�C?�jV1. dti 3 r—+ — <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),rinseate and debris. I further certify that <br /> the information provided herein is.ttue and accurate to the best of my knowledge. <br /> SI ATURE OF GERTIPER 7Ce <br /> TION'OF CERTIFYING PERSON <br /> tive ofthe CUPA,authorized agency,or LIA: 760. <br /> NAME OF CERTIFIER (Print) 754• <br /> ' No <br /> L C Lt© d ame ofCUPA,authorized agency,or LIA: 761. <br /> TITLE OF CERTIFIER 755. N/A <br /> Z–.c. L tti h(i-vCC1If certifier is other than CUPA/LIA checkaPp P <br /> ro riate box below: 762- <br /> DRESS 756. <br /> IN � <br /> c� <br /> ❑ a. Certified Industrial Hygienist(CIH) <br /> V i 50 ❑ b. Certified Safety Professional(CSP)- <br /> C}TY 7s7. <br /> 0c. Certified Marine Chemist(CMC) <br /> r <br /> L) ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE 758. <br /> Q ❑ e. Professional Engineer(PE) <br /> S ^ V ❑ f. Class II Registered Environmental Assessor <br /> 759. <br /> DATE CERTIFICATION TIME 11 & Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> 2 -S -0a, 10% 00 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (If Yes,the to k interior atmosphere shalt be redredted witha combustible gas indicator prior to wwk.being conducted onthe tank.) 181 Yes ❑ NO <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: <br /> 764. <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure(i.e.CUPA or other authorized local agency); tha <br /> owner and/or operator ofthe tank system;and the tank removal contractor. <br /> UPCF HWF1249(1/99)-1/2 http:7/wtvw:ttnidties drg Re*.02/16/00 <br />