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UNIFIED PROGRAM CONSOLIDATED FORM <br /> ' HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> ' Page 1 of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(samem FACII.[TYNAMEm DBA-Doin aaa M) 3. FACB.TTYID# t. <br /> Cr - S %. 1 t �'• <br /> TANKO RNAME ]ao <br /> GI 6 U 7 t✓l I { i—a( .{' L? <br /> TANK O R ADDRESS 741' <br /> ' 70 , w6f' <br /> TANK OWNER CITY a2e7 <br /> 42 ]43.STATE ZIP CODE 744. <br /> H. TANK CLOSURE INFORMATION <br /> ' toe�o Cvn�� Tank ID# Concentration of Flammable Vapor .. . <br /> o"( (Amrli.aammvl eopim Concentration of Oxygen <br /> of'mia Pabe famm°dw Top Center Bottom Top Center Bottom <br /> TANK ilueenNo) <br /> INTERIOR ]4. ]46a ]466 v M. Z- ]4]a Z ]4T6. Z 747e <br /> ATMOSPHERE l 8^i'6$n e3 •'rte , <br /> ' RF,ADMG$ ]da TA749h 745t ]5 <br /> ]O <br /> '02 � 7 <br /> $°66w'. <br /> 3 751. TSh 752b —'stn 753a —' 7936. �^ 753c <br /> ' HL 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 true and accurate to the best of my knowledge. <br /> SI ATORE OFRT R STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> z o K '/-6 tl Certifier is a representative of the CUPA,authorized agency,or LIA: 7W. <br /> NAME OF CERTIFIER75°' <br /> (ihim) 1:1 Yes 0 No <br /> CLbd Name ofCUPA,authorized agency,or LIA: 76t. <br /> TITLE OF CERTIFIER 55. N/A <br /> S L w v-z:-vzo v-- If eertifier is other than CUPA/LIA check appropriate box below. 762 <br /> DRESS756. ❑ a. Certified Industrial Hygienist Y&enist(CIH) <br /> V r 3 ❑ b. Certified Safety Professional(CSP) <br /> CITY 757' ❑ c. Certified Marine Chemist(CMC) <br /> 0 ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE Tsa. <br /> ❑ e. Professional Engineer(PE) <br /> S-30 - 9 '2& - 3 ❑ f Class 11 Registered Environmental Assessor <br /> DATE 759. CERTIFICATION TIME Conuactors'State License Board licensed contractor(with haaardous <br /> ' substance removal certification) <br /> iZ -S -O8' 10'. 00 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS ] <br /> (Um,WawJt intmioratmmph.Aallcom dblepal iodiawprier mwak.6dne wnaoated m the nekE.) }res ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 76q. <br /> A copy ofthis certificate shall accompany the tank to the reeycling/disposel facility and be provided to the agencyoversee tank closure i.e.CUPA or other authored 1=1 the <br /> owner and/ora operator o£tbe leek ( agan9y). <br /> pe system;end the took removal contractor. <br /> 1 UPCF HWF1249(1/99).1/2 http://W".unidocs.drg Re*.02116/00 <br />