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02/01/2006 17:20 FAX 510 614 8396 PARADISO MECHANICAL Z016 <br /> UNI IED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> 1 1 <br /> page Of <br /> I.FACILITY IDENTIFICATION <br /> I. <br /> BUSINESS NAME(some as FACILITY NAME or DBA-Doing Bu5inrs As) 7' PAC]L1TY lD# <br /> e2�-u .tn JSr�r 'C'�.X71 1T .ii�n•r'-1 a�� 1]C)' �''�'r1 L:l � _5 9521? <br /> 740, <br /> TANK OWNER NAME <br /> 741. <br /> TANK OWNER ADDRESS <br /> TANK OWNER CITY 742STATE 4W 7'13' ZIP CODE 744 <br /> H.TANK CLOSURIu INFORMATION <br /> IDN Concentration of Flammable Vapor Concentration of Oxygen <br /> nddiGonal copies <br /> of this pme rer more 0= Top Center Bottom Top Center Bottom <br /> Wee ranks) <br /> 7462 14rp 746c, t 7470. 7476. ,7 n 747e. <br /> INTERIOR t R <br /> ATMOSPHERE l 5S!27 las, -F. <br /> READINGS Z 746, 149a- 749h. 749c. 750 7500, 7506. <br /> 3 <br /> 75L 75zs. 75zh 75zr. 759x. 7i3b. 7536. <br /> III.CERTIFICATION <br /> On examination of the tank.I certify the tank is visually free frotn product,sludge,scale(thin,flaky residual of tank contents),ring???and debris.I further certi- <br /> fy that the information provided herein is true and accurate to the but of my knowledge. <br /> SIGNATURE OF RTIFIL•R STATUS OR AFFILIATION OF CERTIirYING PERSON <br /> Ccrvficr is a rcpreseatative of the CUPA,authorized agency,or LIA; <br /> 760, <br /> NAMI;OF CERTIFIER(Print) 154- ❑ Yes Na <br /> 761. <br /> Name of CUPA,authorized agency,or LI <br /> TCILE OF CERTIFIER 755, NIA <br /> _ 762 <br /> If certifier is other than CUI'A/L1A check appropriate box below: <br /> ADDRESS 756• ❑ a, Certified Industrial Hygienist(CIH) <br /> 23353 (/1.r,I19 t•i] ❑ b. Certified Safety Professional(CSF) <br /> CITY 757• )K e. Certified Marine Chemist(CMC) <br /> 7,irlY�':f.."tai '�_� �'f' ' '-1 ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE 75R. O C. Professional Engineer(PE) <br /> 51C-533-0075 ❑ f. Class 11 Registered Environmental Assessor <br /> DATE 759. CERTIFICATION TIME O g. Contractors'State License Board licensed contractor(with <br /> hazardous substance removal certification- <br /> 163- <br /> TANK PREVIOUSLY FIELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> YnS C] No <br /> (If yes,the tuck Interior atmosphere shall be re-checked with a combustible gas indicutnr prior to work being completed on the rank_) <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC. <br /> 764. <br /> WISCO RQA'_i LANDFILL TANKS/PIPING MEETS TITLE 22 REQUIREMENTS <br /> 4�J01 T. VASCC ROAD <br /> C_"-_ ^',55n CRUSH WITHHEAVY EQUIPMENT <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure(i.e.CUPA or other <br /> authorized local agency);the owner and/or operator of the tank system:and the tank removal contractor. <br />