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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 FACILITY ID# l <br /> TANK OWNER NAME 740 <br /> TANK OWNER ADDRESS 741 <br /> TANK OWNER CITY 742 STATE 743 ZIP CODE 744 <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than To Center Bottom To Center Bottom <br /> TANK three tanks) P P <br /> INTERIOR1 745 746a 746b 746c 747a 7476 747c <br /> ATMOSPHERE <br /> READINGS 2 748 749a 749b 749c 750a 750b 750c <br /> 3 751 752a 752b 752c 753a 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 certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> NAME OF CERTIFIER (Print) 754 ❑ Yes ❑ No <br /> Name of CUPA,authorized agency,or LIA: 761 <br /> TITLE OF CERTIFIER 755 <br /> If certifier is other than CUPA/LIA check appropriate box below: 762 <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CSP) <br /> CITY 757 ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 758 [j e. Professional Engineer(PE) <br /> ❑ f Class II Registered Environmental Assessor <br /> DATE 759 CERTIFICATION TIME ❑ g Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> (If yes,the tank interior atmosphere shall be re-checked with a combustible gas indicator prior to work being conducted on the tank.) ❑ Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764 <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the CUPA. If there is no CUPA,copies shall be submitted to the LIA and authorized <br /> en •owner/operator of the tanksystem;removal contractor,and the recycling/disposal facility. <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />