Laserfiche WebLink
t <br /> UVIF'IED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WA.S`1V, <br /> HAZA,"OL-S WASTE TANK CLOSURE CERTIFICATION i <br /> e of <br /> I.:-.ACuU,1Y IDjNTIF'ICATIO 1 <br /> DUSINFSS NAME f�n encni7Y NA>�E nr➢sA-Ub M A81 <br /> 3. FACTLfl'Y D# w <br /> 40, <br /> rRNic OWNPR NAWE <br /> 41 <br /> TA.\K OWNER ADDRESS IJ <br /> -y Iva. <br /> STATE 4r�y—742. zlp Cvne � !✓�,. <br /> -- <br /> TA'4R OWNER C n y i✓1 <br /> , <br /> TAR'K-CX.flSUfiE�!T''ORN!?TION <br /> :nn0crttrauass( .. <br /> _ of oxygen <br /> Tartlt ID A J Concenlruinn ofFlummabla Vapor <br /> e a.en vwmw eov;� <br /> .i.� Cexuer Bottom <br /> am wee fo1 eanre zhm, It p Center Burnet <br /> TANT _ /�Ufaunu) 7s7. 747b, 747c. <br /> N EWOR l V a 1 O 7560 750b. 7500. <br /> ATMOSPHOU 748, Sc 749x. 744x. 744c, <br /> REALIINDS 2 i — 752b 7330 753& 536. 7534 <br /> - 7st. nm <br /> 1YT'.CERTTF'1CATI ior�' <br /> _ - from <br /> °^ s e scwe titin,flaky residual of tmSc e�+wsu),"b de 2nd debris. 1 fuNser certify lh4 <br /> tot ex.mination of I it tank.I certify the tank is Tn r knowledge. ` <br /> 111e urfsrmati0n proi ided he:rcul is true and w4urate o the test <br /> 5IGNATURI O RTiI'!I~ STATUS OR�.FF11-IATION OF CEitTIFYB�G PERSON 760. <br /> Certifier is a sepresentalivs of the CtJPA,adtlloslzed agency,W[.IA: <br /> 7S4. El Yes 0 140 <br /> N F :T <br /> CE IF IER (�1'v J� 760. <br /> �'� �9 � NBtnc of CL1YA,8uthoriad agrx+e5',or LTA' <br /> 755. <br /> NIA 762 <br /> TITLE OF CE�RT/IF.EFt �v ap box belou- <br /> 7/ 1 4�/ If certifier is Other thm CUPA 1 LIA check ;rr%r� <br /> 7s" a Certified lndostrial Ilygieniat(CIM <br /> ADDRESS <br /> b. CenifiedSafetyProfessionaf(CSP) <br /> FC <br /> Certified Marine Chemist(CMC.) <br /> Crrr F,avir0tcnernal Health specialist(REiis) <br /> + p Q Regiaterad <br /> — —— 77Y e. Profcasionat Enginm(PE) <br /> PHONIE <br /> ©��L Class lI Registered FaWirnnrnenial Asaessof <br /> (� !� 17�C c. Con=IWS'State license fiord licensed contr9ctor(with hn7.ardous <br /> 7 9 CERTTPICATION'l`IAIE � subsiance removal certification) <br /> DATE <br /> })� <br /> 763. <br /> TANK PREM t'S YHELDF1JtMMAS1t [rRCOMSU5fIRLEMATEMIALS r--a <br /> vwceo<bmrw..arx leM0 cq sdmdr MIL -Yes LJ NO <br /> Il!ties at»tsdo mtm,a evnpaxe eha0 k re�etW,.;w.c amt nwa'trc a� 7G4. <br /> CERTIi'18R"8 TA, ANAG ,EMEVr INSTF:Utt10NS FOR SCRAP DEALER,DLSPOSAL FACILITY,EIC! <br /> !IC M <br /> •copy <br /> ofhl cervi fu pie,ru:uwm�+ry the unk u.dere reeYel�Nd'�/O'-'l&cilay and be provided to the agency overseeing tml dutwe(i.e.CUPA or otder authorized font aaeuq)'. the <br /> Q—er wVV=op tio,o f rhe Teri.AVuel r,snd[be tAW re"wa wnthaor. <br /> tiPCFkiWl•'1249 ,1199)-l/Z <br /> http:IMlv,v.unldors.0rp Rev.02116(00 <br /> Td Wd�b:TT Vow 80 -1013 TS8T 892 60Z T: 'ON XUA -1I0 D&IOH1 WIt: WON3 <br />