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0 <br /> UNIFIED PROGRADE CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> w <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME(S:>m PAOLITYNAME mDBA-Dobeaminw An s FACILITY IDg I <br /> C i T o S"0 Q w <br /> TANK O KERN IE 160 <br /> T <br /> TANK OWNER ADDRESS ( 'al <br /> 4Z5 �. �J Doy�a�u St , 3vr� �I9ov n .^ <br /> TANK OWNER CITY L STATE (:4(1 a ZIP CODE 5�-2,0 ZL 1a` <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID p Concentration of Flammable Vapor Concentration of Oxygen <br /> Umrh addidaml ml:m <br /> ora��wels) n.n TOP Center Bottom TOP Center Bottom <br /> TANK '7ry <br /> ATMA OR l Z�J� 11I3 ]aha 1a66 ]Me �ht]. r/.]b <br /> READINGS ' 77 % u 74rtne% <br /> J`r4 ]s ]soc <br /> 3 ]al ]a]a ]sla ]]ID <br /> is]c <br /> III. CERTIFICATION <br /> On examinauon of the tank,l certify the Tank is visually free from product,sludge,scale(thin,flaky residual of tank contents),rinseme and debris. I further certify that <br /> the ipllImation provided herein is we and accurate to the best of my knowledge. <br /> SIG REOFC T JER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> `s 94 .0h Certifier is a representative of the CUPA,authorized agency,or LIA: ]6a <br /> NAME OF CERTI (Pn,) ISa ❑ Yes L9 no <br /> SC n UC n KJ61, Name of CUPA.authorized a en ]6t <br /> g agency,or LIA: <br /> TITLE OF CERTIFIER 75 <br /> If certifier is other than CUPA/LIA check appropriate box below: 1b2 <br /> DRESS 156 ❑ L Certified Industrial Hygienist(CIH) <br /> �01 X16 01 <br /> ❑ b. Certified Safety Pmfessional(CSP) <br /> C 131 <br /> CITY [3 Certified Marine Chemist(CMC) <br /> ITY <br /> r0 ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE a <br /> ry (� ❑ e. Professional Engineer(PE) <br /> �❑�f Class It Registered Environmental Assessor <br /> DATE <br /> ]s9 ION TIME <br /> CERTIFILLK g Contractors'State License Bond licensed contractor(with hazardous <br /> CAT <br /> C substance removal certification) <br /> 1 J 0 <br /> W <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COaaRUSTiBLE MATERIALS <br /> nrym the uet emeur plphrt"i b.�wwiA.nombnebkry india mor to ova veins madunedonthe®k) Gy Yea ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 96e <br /> A copy oflhis cnu6carc shall acc mnpagv the tank to the recycling/disposal fwility and ee Provided to the CUPA Ifffi m is no CUPA.copies shall be subtnimuct to the LIA and suthonrcd <br /> a,;ower,/o torofthe tank .m removal contractor end the rccvch. I dinesalfadli . <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />