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l <br /> UNIFIED PICOGRAM CONSOLIDATED FORM y D <br />. .. riAZAlprs� ' <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION' <br /> EWRONMENTAL H LTH <br /> I, FACILITY IDENTIFICATION pa of <br /> BIISI SSIiIAMF:(S"n"sFACtUrYNAME9rDRA—Dofngjiuslue"As) 3 VACILITYID# <br /> J__C,e <br /> TANK O W R NAND& <br /> I4 CS� S Tao <br /> TANK OWNER ADDRESS <br /> 141 <br /> TANK OWNER CITY }i(��J{!•dJ C� raz <br /> _ STATE 741 <br /> C' ZIP CODE �' <br /> s I.L TANK CLOSURE INFORMATION � <br /> Tank ID# Concentration of Flammable Vapor <br /> r sch addldonal copisv <br /> T K ofthfsp�ero�tmorolhan To. - Concentration of Oxygen <br /> INTERIOR' 1 P Center Bottom Top Center <br /> Bottom <br /> ATMOSPHERE I S las �- D 9464 � 746b D 746e �747a 47b 7c <br /> READINGS <br /> Z - 746 749: 749b � - <br /> 749c 7$pa <br /> 3 751 7526- .. 752a 7506 <br /> 7504 <br /> _ <br /> ,...,...--..„ ..-. 752 733 sib 7 751 <br /> TII. CERTIrICATTON <br /> On examination of the tank,I certify the tsnk is visually free from product,sludge,scalethin,t2 <br /> Q is true and accurate to the best ofmy knowledge. ( �7 residual of tank contents),rinses;e and debris. I further certify that <br /> the information provided h <br /> S IGNATURE OF C TIFIER <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> OF CE TIFIER <br /> Lt'/�. Certifier is a representative of the CUPA,autborized agency,or LIA: 760 <br /> (Atnr) 754 <br /> ❑ Yes r-4 No <br /> TITLE OF C TIFIER Name of CUPA,authorized agency,or LIA: 761 <br /> � 75s <br /> ' /�� /i✓ <br /> ADOREIfcmiifier is other than CUPA!LIA check aPPro nate box below: 762 <br /> S 756 P <br /> ( ax 7 E3 a- Ceriifted Industrial Hygienist(Crm) <br /> CITY <br /> ❑ b. Certified Safety professional(CSP) <br /> 757 <br /> LQ c. Certified Marine Chemist(OMC) - <br /> t I / ❑ d. Registered Environmental Health Specialist(RENS) <br /> PRONE 7s <br /> �� � �� / ❑ e, Professional Engineer(PE) <br /> ❑ f. Class II Registered Environmental Assessor <br /> -DATE 7s9 <br /> CERTIFICATIONT. L ,COnrrac1Ors'State License Board licensed contractor(with.hazardous <br /> /� substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> +y/I <br /> �/ 1 <br /> (tfyns,aW tank INuierat nwphae rhea be toch ckcd with a combu36ble gts inditalor prier to work bctngwnducledon the tame) 763 <br /> CERTIF)ER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILI fY EIC; 764 <br /> YC3 0 No <br /> _z <br /> O SOlt �� <br /> A ct+py.of this ecrtifieato shall accompany the tank fn'Ihr recycling/disyosal facility end be prvvidrd to the CUPA, IFthrre Is no CUPA,copies she][be su6mirted to Use LIA and authorised <br /> a toe �owner/o crater of the tank stem•tumoral contractor and the reo eiin /di osal fact!; • <br /> UPCF(I V99) <br /> Formerly DTSC 1249(6/98) <br />