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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> I. FACILITY IDENTIFICATION Pte of <br /> BUSINESS NAME($ame u FACILfr Y NAME or DBA—Doing Baslam M) 3 FACILITY ID# <br /> TTI ITT <br /> 1 <br /> C/l-- v/J / vC� / <br /> TANK NER NAM& S <br /> Tao <br /> CI �iJi � 'q C, moo / <br /> TANK O AD—vec <br /> xoi� 741 <br /> TANK O WNER CITY G62 v r 7a1 <br /> STATE C 743 ZIP CODE <br /> II, TANK CLOSURE INFORMATION <br /> Tank.a # Concentration of Flammable Vapor <br /> of this <br /> ago fornalcopier Po Concentration of Oxygen <br /> *(this pago for mora Lhan <br /> TANK lute to kj) Top Center Bottom <br /> INTERIOR J 7a5 7a6a Top Center Bottom <br /> ATMOSPHERE I ��� 7466 /, 746c 747. 7476 7a7c <br /> READINGS 749a 0 � / � / <br /> 2 748 749b 749c 750a <br /> 7506 7 c <br /> j 751 7521 7526 752c <br /> 733a 753b 753, <br /> ... ...... .. ...... <br /> III. CERTIFICATION <br /> Ou 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 h 'n is true and accurate to the best of my knowledge. <br /> SIGNATURE OF C TIFIER <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> OF CE TIFIER (> nt) �' 754 <br /> ❑ Yes No <br /> TITLE OF C TIFIER 735 Name of CUPA,authorized agency,or LIA: 761 <br /> If certifier is other than CUPA/LIA check appropriate box below: 762 <br /> ADDRES ? 7s6 <br /> � ❑ a. Certified Industrial Hygienist(CIH) <br /> CITY 757 ❑ b. Certified Safety professional(CSP) <br /> Q c. Certified Marine Chemist(CMC) <br /> / <br /> PHONE ❑ d. Registered Environmental Health Specialist(RENS) <br /> 7s <br /> dC- J.� ❑ e. Professional Engineer(PE) <br /> ❑ f. Class II Registered Environmental Assessor <br /> DATE 759 <br /> CERTIFICATION TIME Az,Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> 763 <br /> (lf yaa,ay t+++k Werior a6naphae shaa dere-ehcrked with a combustible gu inditalor pior ro work being conducted on Ut•WJe) <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: ,Yes Q No <br /> 767 <br /> A COPY*(this certificate shalt accompany the tank to the recycling/disposal facility end be provided to the CUPA, If there is no CUPA,copies shall Dc submitted to the LIA and authorized <br /> a me -owner/o eratorof the tanks stem removal contractor,and the rec clip /disposal ficiG <br /> UPCF(12/99) <br /> Formerly DTSC 1249(6/98) <br />