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02/01/2006 17:19 FAX 510 614 8396 PARADISO MECHANICAL r f�j013 <br /> UNIFIED PROGRAM CONSOLIDATED FORINT <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> 1 � <br /> Page —of <br /> I.FACIILITY IDENTIFICATION <br /> BUSINESS NAME(sone as FACILITY NAME or DBA—Doine Bu>ine8s Al) 3' LLLU <br /> FACILITY ID 11 <br /> r <br /> i�r�''.._? /1r1°.�Ja� — 02�� •J. tT4_z-�T'�J C`J` '1'1LT' , V� <br /> 74. <br /> TANK OWNER NAME <br /> TANK OWNER ADDRESS lit <br /> TANK OWNER CITY 74z STATE 143' ZIP CODE 7A" <br /> II_TANK CLOSURE INFORMATION <br /> T;mk 1D A Concentration of Flammable Vapor Concentration of Oxygen <br /> (AEE==addldonal copies <br /> of rhi5 paCe for mom thun Center Bottom Tap Center Bottom <br /> TANK ,hree tanks) p <br /> INTERIOR 1 1 7a5• 746x. 746b. 74&. 747a 717b• 7J7c. <br /> ATMOSPHERE ' �` ?-� G�- <br /> R$ADINC,S 745. �? 749s t° 7496. pJ 749r. 7,^ 1 750x. O 7546. 7 p 7506• <br /> 751 752x. 752b, 752C• 753;. 753b. 753b. <br /> 3 C»7 ���� <br /> J_1J. JlL <br /> III.CERTIFICATION <br /> On examination of the tank,I certify the tank is v' wally free from product,sludge.Scale(thin,flaky residual of tank contents),rin????and debris.I further certi- <br /> fy that the information rovidcd herein is ttu d ccuratc eo the best of my knowledge. <br /> rSIATWRTIFIER STATUS OR AFFILIATION OF CER'T'IFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: <br /> 760. <br /> ME 0 CERTIF tint) 754, ❑ Yes R No <br /> t? `cam•/ ;•" t : i? ��;• PA,authorized agency,or LIA;. 761. <br /> .--�,.,..-- '•-- —'�--,�_.�.�_1 Name of CU <br /> TITLE OF CERTIFIER 755' N/A <br /> If certifier is other than CUPA/LIA check appropriate box below; 762. <br /> --..._... .. ..---....tom. <br /> ADDRESS 756. ❑ a_ Cer6ficd Industrial Hygienist(CIH) <br /> 2 °5:, ';,ajZj >?TT., ❑ b- Certified Safety Professional(CSP) <br /> CITY 757. c. Certified Marine CherrliSL(CMC) <br /> Y's';?fir .", Gllt�/•}1 ❑ d. R-gistered Environmental Health Specialist(REHS) <br /> PHONE 158- ❑ e, Professional Engineer(PE) <br /> 51 -3,_0075 ❑ f. Class 11 Registered Environmental Assessor <br /> DATE 759• CERTIFICATION TIME O g. Con[raetors'State License Board licensed contractor(with <br /> hazardous substance removal certification. <br /> /NK P VIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (If yea,the wnk interlor atmosphere shot)be rechecked-iih a=btisdble gns indicator prior to work being completed on the tank) Yes 0 No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ECC. 76a. <br /> f; 1 „. V,h S� 71 L TANKSIPIPIN•G MEETS TITLE 22 REQUIREMENTS <br /> L7'✓=' � 's, C_' 9155) CRUSH WITH HEAVY EQUIPMENT <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the a;ency overseeing tank closure 0-e-CUPA or other <br /> authorized local agency);the owner and/or operaLor of the(ank system:and the tank removal contractor. <br />