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Hazardous Waste Tank Closure Certification Complete and submit this page prior to initiating any cleaning, cutting, dismantling, or excavation of a tank system that meets the conditions below: Any tank system that previously held a hazardous material or a hazardous waste, that is identified as a hazardous waste, and that is destined to be disposed, reclaimed or closed in place. This does not apply to tank systems regulated under a hazardous waste facility permit, other than permit by rule (PBR), or to tank systems regulated under a grant of interim status, nor to a tank system or any portion thereof, that meets the definition of scrap metal in 22 CCR §66260.10 and is excluded from regulation pursuant to 22 CCR §66261.6(a)(3)(B). Refer to 22 CCR §67383.3 and 23 CCR §2672 for disposal requirements for tank systems. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section ofthe Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER- Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME -Enter the full legal name ofthe business 740. TANK OWNER NAME - Complete items 740-744, unless all items are the same as the Business Owner 741. TANK OWNER ADDRESS information (items 111-116) on the Business Owner/Operator Identification page 742. TANK OWNER CITY (OES Form 2730). If the same, write "SAME AS SITE" across this section 743. TANK OWNER STATE 744. TANK OWNER ZIP CODE 745. TANK ID NUMBER 1-3 - Enter up to three owner's tank ID numbers. This is a unique number used by the owner to identify the tank If more than three tanks are being closed, complete additional copies of this page. (Enter additional tank numbers in 748 and 751.) 746. CONCENTRATION OF FLAMMABLE VAPOR 1-3 - Enter three interior flammable vapor levels for each tank being closed, taken at the top, center, and bottom ofthe tank. (For more than one tank, enter additional tank readings in 749 and 752.) 747. CONCENTRATION OF OXYGEN 1-3 - Enter three interior oxygen levels for each tank being closed, taken at the top, center, and bottom ofthe tank. (For more than one tank, enter additional tank readings in 750 and 753). SIGNATURE - The business owner or officer ofthe company who is authorized to make decisions for the facility and who has operational control, shall sign in the space provided. 754. CERTIFIER NAME -Enter the full printed name of the person signing the page. 755. CERTIFIER TITLE - Enter the title of the person signing the page. 756. CERTIFIER ADDRESS - Enter the address of the person signing the page. 757. CERTIFIER CITY - Enter the city for the signer's address. 758. CERTIFIER PHONE - Enter the phone number for the person signing the page. 759. DATE CERTIFIED - Enter the date that the document was signed. Enter the time that the readings were taken. 760. CERTIFIER REPRESENTS LOCAL AGENCY - Check "Yes" ifthe person certifying the tank is a representative ofthe CUPA, authorized agency, or LIA, check "No" if not. 761. NAME OF LOCAL AGENCY - Enter the name of the local agency represented by the person certifying the tank. 762. AFFILIATION OF CERTIFYING PERSON - Check the certification, license, or organization which the certifier holds or to which the certifying person belongs, if not a CUPA/ LIA. 763. TANK HELD FLAMMABLE OR COMBUSTIBLE MATERIALS - Check "Yes" if the tank held flammable or combustible materials, check "No" if not. 764. MANAGEMENT INSTRUCTIONS - Provide tank management instructions to the scrap dealer, disposal facility, etc., in this space. UPCF (12/99) 40 Formerly DTSC 1249 (6/98) PNP0012767