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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />page of <br />I. FACILITY IDENTIFICATION <br />BUS NESS NAME (Same as FACQ.rfY NAME or DBA —Doing Business As) 3. <br />rLITY5FI. <br />740. <br />TANK OWNER NAME <br />741. <br />TANK OWNER ADDRESS <br />q &cl Z 51wo of Ozll ` tib <br />TANK OWNER CITY Wtt/ "/11 742. STATE 743. ZIP CODE <br />11. TANK CLOSURE INFORMATION <br />Tank: ID # <br />Concentration <br />of Flammable <br />Vapor <br />Concentration <br />of Oxygen <br />(Attach additional copies <br />of"s page for more than <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />"IT RIOOR <br />three ranks) <br />I 745. <br />r, 746a <br />746b. <br />/, 746e. <br />747a <br />7476. <br />/ 747c. <br />ATMOSPHEREIN <br />READINGS <br />748. <br />744a <br />7496. <br />749c <br />/1P -750a <br />/ 7506. <br />/ / 75 0c <br />3 751. <br />752a <br />/r 7526. <br />y� 752c <br />— 753x. <br />/� 7536. <br />/�• 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 CERTIFIE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />760. <br />Certifier is a representative of the CUPA, authorized agency, or LIA <br />❑ Yes ® No <br />761. <br />-S��— 7s4. <br />NAME OF CERTIFI runt) <br />F-0 Fd P ---VY-- <br />Nance of COPA, authorized agency, or LIA: <br />NSA <br />TITLE OF CERTIFIER �/�j /� �` , M y/��C� 75s. <br />I P v47 &yP 6&o E " � <br />p,�-� O ��"' �! � <br />762. <br />If certifier is other than CUPA / LlA check appropriate box below. <br />❑ a Certified Industrial Hygienist (CIH) <br />756. <br />ADDRESS <br />5 7 n-I�W A7A?9 <br />❑ b. Certified Safety Professional (CSP) <br />❑ c. Certified Marine Chemist (CMC) <br />757. <br />CITY <br />��- <br />❑ d. Registered Environmental Health Specialist (RENS) <br />❑ e. Professional Engineer (PE) <br />759' <br />PHONE <br />jf/) �/ / J <br />❑ f. Class II Registered Environmental Assessor <br />700 <br />Contractors' State License Board licensed contractor (with hazardous <br />759. <br />DATECERTIFICATION TINE <br />substance removal certification) <br />� <br />763. <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />with a combustible s indicator prior to uvrk being conductedon <br />(byes, the tank interior aunosphere shill be rc checked wpp <br />the tank) It7 r El NO <br />CERTIFIEWS TANK MANAGEMENfT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: W. <br />A copy of dris certificate shall accompany the tank: to the recycling/disposal facility and be provided to the agency overseeing tank: closure (i.c. CUPA or odter audtoriud local agency); the <br />owner and/or operator of the tank system; and the tank removal contractor. <br />UPCF HWFI249 (1/99) - If2 www.unidoes.org Rev. 02116/00 <br />