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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />7526 752c 753. 753b 753c <br />Pre of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same u FACILMY NAME or DHA- Doing 6asineu As) 3 <br />FACILITY ID# <br />SIGNATURE OFC TIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />L� <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 760 <br />OF CE TIMER (P Int) /' <br />754 <br />❑Yes No <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OFF CERTIFIER <br />755 <br />/ <br />If <br />certifier is other than CUPA /LIA check appropriate box below: 762 <br />ADDRES <br />y <br />ox <br />Cr.7 0/ J c / <br />✓ <br />❑ b. Certified Safety professional (CSP) <br />CITY <br />757 Q c. Certified Marino Chemist (CMC) <br />/ ❑ d. Registered Environmental Health Specialist (REHS) <br />PHONE <br />J/ <br />75 <br />❑ e. Professional Engineer (PE) <br />❑ <br />f. Class II Registered Environmental Assessor <br />DATE 7s9 <br />CERTIFICATION TIME <br />�,� Contractors' State License Board licensed contractor (with hazardous <br />substance removal certification) <br />TANK O NER NAXJ& Tao <br />G/ V .v.-. <br />TANK OW AD—^ cc Tat <br />- <br />TANK OWNER CITY L/— v r 14` I STATE ZIP CODE G 7m <br />II. TANK CLOSURE INFORMATION <br />Tank ID # Concentration of Flammable Vapor (A Bach addidorul wpim po Concentration of Oxygen <br />of this pogo for rnoro than <br />TANK u,reeunks) Top Center Bottom Top Center Bottom <br />IM I OR ) 745 7aba 746b I7a�r <br />READINGS749b <br />2 748 749. <br />7490 750. 7506 750c <br />sl <br />3 77sz. <br />7526 752c 753. 753b 753c <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 ecrtify that <br />the information provided h 'n is true and accurate to the best of my knowledge. <br />SIGNATURE OFC TIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />L� <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 760 <br />OF CE TIMER (P Int) /' <br />754 <br />❑Yes No <br />Name of CUPA, authorized agency, or LIA: 761 <br />TITLE OFF CERTIFIER <br />755 <br />/ <br />If <br />certifier is other than CUPA /LIA check appropriate box below: 762 <br />ADDRES <br />y <br />ox <br />756 <br />C1Z s. Certified Industrial Hygienist (CIH) <br />✓ <br />❑ b. Certified Safety professional (CSP) <br />CITY <br />757 Q c. Certified Marino Chemist (CMC) <br />/ ❑ d. Registered Environmental Health Specialist (REHS) <br />PHONE <br />J/ <br />75 <br />❑ e. Professional Engineer (PE) <br />❑ <br />f. Class II Registered Environmental Assessor <br />DATE 7s9 <br />CERTIFICATION TIME <br />�,� Contractors' State License Board licensed contractor (with hazardous <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />(Irya, au hank Interior ebnasphcte Shan be rocheekod with a whnbuslibto gu indiutor prior to work being conducted on the tank) <br />Ycs ❑ No <br />CERTB=IER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER nlepncer cn rn h-r-ar r>,,... <br />A copy -of this certificate shall auornpany the tank to the recycling /disposal facility and be provided tv the CUPA, If them is no CUPA, copies shall be submitted to the LLA and anrhr,r;>,.,1 <br />agency;.. tier <br />/ODefalof Oflbe tank systeat; rtmoval Contractor and the --f;— r__. — <br />UPCF (12/99) <br />% 7 <br />Formerly DTSC 1249 (6/98) <br />