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UNIFIED PICOGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ,.., HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> ' Pae d <br /> I. FACILITY IDENTIFICATION <br /> BUSIPT M.NAME(Same a FACILITY NAME or DDA-Weill Business As) 3 FACILI'I1'UD# l <br /> t.� 6c" <br /> TANK NAME 740 <br /> K <br /> C <br /> r.a TANK OWNER ADDRESS 741 <br /> TANK 0!N:E:RCITY 742 STATE 743 ZIP CODE 9 y6' 7" <br /> s,r <br /> II. TANK CLOSURE INFORMATION <br /> Tank IDM Concentration of Flammable Vapor(Attach additional eapio po Concentration of Oxygen <br /> of this pqe for more Llan <br /> TANK three tanks) Top Center Bottom Top Center Bottom <br /> 1 <br /> ATMOSPHERE � /(J R 743 - 7f(r > 7466 746c Q� 47a 747b 747c <br /> l �d � <br /> READINGS 2 748 749. L �� 4,7496 749c /;sa 7sob 750c <br /> L.a 751 752a / 752b 7S2c <br /> 3 753a 7536 753c <br /> M. CERTIFICATION <br /> a.+ 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 <br /> that'the information provided herein is true and accurate to the best of my knowledge. <br /> OF CE R STATUS OR AFFILIA'T'ION OF CERTIFYING PERSON <br /> 1.r <br /> Certifier is a representative ofthe A,authorized agency,or LIA: 760 <br /> NAME OF RTIFIER (Print) 754 <br /> ❑ Yes No <br /> &+ 6 r Name of CUPA,authorized agency,or LIA: 761 <br /> TIT O ERTIRER 755 <br /> If certifier is other than CUPA/LIA check appropriate box below: 762 <br /> a.� <br /> ADDRES 756 <br /> ❑ a. Certified Industrial hygienist(CIH) <br /> �� <br /> ❑ b. Certified Safety Professional(CSP) <br /> CI 7s7 <br /> ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE Tse <br /> ❑ e. Professional Engineer(PE) <br /> Ta �— 49& d- ] <br /> E] f. Class TI Registered Environmental Assessor <br /> DATE 759 CERTTFICATTON 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 imeriar umosphem shill be rechecked with■combustible am indicator prior to work being eondwLod on the unk.l Yes ❑ No <br /> CERTRFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, I POSAL FACILITY, ETC: 764 <br /> A copy of this certificate scull accompany the tank to the recycling I disposal racility aM be provided to the CUPA. If there is no CUPA,copies shall be submitted to the LLA and <br /> audwrired ajMv owner lomrao f the an'r vel ntncto and the rec i /disposal facility. <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/99) <br /> V <br />