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UNIFIED PROGRAM CONSOI DATED FORM <br /> IMAZARDOUS WASTE <br /> HAZARAOUS WASTE TANK CLOSURE CERTIFICATION <br /> page1 of I <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAW(s.m...Facmaymam w mA-ndtyE..ow.A.) x FACI.I moit <br /> l..t L <br /> TANKO NAME ,,w. <br /> t <br /> L b v 12 { w t3 <br /> TANKO ADDRESS 741. <br /> lo( w esc— <br /> TANKOWNERCITY 742, STATE. AP CODE Tal <br /> IL TANK_CLOnM INFOitIVIATION. ...: <br /> (0co6r, ' an <br /> 1 (Ata.addidaa T.MmeedR ow CmenmonofFlammable Vapor ConcentrationConcentration of Oxygen <br /> fta <br /> TANK a�+b<�••sdo) am Top Coater Bob= Top Center Bottom <br /> ATHf B0.6RRE I -CSIIS' .,�"�+e. vao. ,am -�.L �n` 7. 2.. ''M 7, 1- 74T <br /> aeanm cs _ 2 vea us. +.se ,� �D *w. ,2 'sa Z O �1 <br /> Sao(7N.Uo jI./ '' —+51. 70, <br /> III. CERTIFICATION <br /> On=unmation ofthe tank,I certify the tank is visually fi=fia m product,sludge,scale(tlirr,flaky residual ofmnk a«dea bl finest,and debris. I father on'*that <br /> the in(CRnatioa provided herein is we and accurate to the Eta nfow knowledge. <br /> SI ATURE OFT .R STATUS OR APPtidATTON OF CERTIPVDIG PERSON <br /> - crrk �/a CD Certi.Sw is a TeMaeutative of the CUPA,audwrized agency,«LIA: 76D. <br /> NAME OF CERTIFIER Rid ❑ Yea ® No <br /> `gNuat ofCUPA,authorized agency,or LIA: 761. <br /> 19 <br /> TITLE OF CERTIFIER N/A <br /> Z-s L'v Ifcutifirr is other than CUPA/LIA check appsopriate bac below: <br /> 7w- <br /> DRESS 7S& Q a Cerrifed Industrial flygiemst(CIH) <br /> -�) 3O)', ❑ b. Certified Safety Professional(CSP) <br /> CITY 'f' ❑ u Certified Marine Chemist(CMC) <br /> y.� a4 9 0 (] d. Registered Emirwtmereal Health Specialist(REBS) <br /> PONE z ❑ e. Professional Engineer(FE)' <br /> CS-10 $78 _G 0 ❑ £ Class 11 Registered Environmental Assessor <br /> DATE rss. CERTIFICATTON TM M'& Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certificuion) <br /> iZ —S —OYf ID'. OD <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS ,,� ��" <br /> (Ityak wAi. ri.r W phae.h.0 k,.b helwlM.mg4a0ekBUN®amr pi.wvmk kuw &Wa mme MXLIJ Yes ❑ No <br /> CERTIFIER'S TANK MANAGMANT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,STC: 76a. <br /> A caps ofthia eeti9cala*0 acwuWuv thv teak to the.aayolmydispoeel facility aM beprovW®d m th agracy ovetwewg tank cweme(ie.CUFA«wha awbaimd local•smwy); the, <br /> aware mdF«opetstor o[the ravk r•mm:andtho uwk.soow.l aroFaaar. <br /> UPCV MWFIM(1"-I!2 H�.lhawtaatdtOC/.urg Rrs:UI/IBAO <br />