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11/05/2009 10:16 3105231518 ADAMS SERVICES, INC. PAGE 02 <br /> r <br /> 174MVP PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> of <br /> I. FACLUTY IDENTWICATION <br /> MUSMSStfAMEC;om PACKMXAM—MA-DW.XP .s AN) ' FwC'[LITY[Dn A ^ D <br /> C �4 / <br /> y <br /> TANK OWNzR wAMts 710 <br /> c <br /> iww Ot mxx ADvRFm / ? 741 <br /> TANK OWNER CITY 1 STATE 717 ZIP COIF 7a <br /> 11. TANK CLOStME INFORMATION <br /> Tio*IV Of(AttsdlwOQliia,NgPQ Coras:,rtration of Flammable Vapor Contm(ration oroxygen <br /> a[IMe Dlrr rm wpq tM, <br /> TANK a ne Y.fa) TOP Clatter Banc n Top Center Bottom <br /> rNt7SRt4R 7a t�fr, 7Mq 71bc rnb , 1147ec <br /> ATM 16 � �� o a 7th a <br /> READINCTS Q rs. © �a Prim X70 7e 7s1. Ci t,m J �y*tic <br /> -fZiZ 2 1 <br /> nu <br /> III. CERTTIFICATION <br /> On cxtanhtation of the tank.I certify the Mrtk ks vlstrolly fte Rom PradUtt:311XI L Beak(thin,flaky f0idabl of thnk con6cnte�rinscate and debris. T fwvlor certify that <br /> the information pravided herein is true and accurate to the hast of Illy knmwledge. <br /> SI4 A CI(TW STATUS OR AFFILIATION OF CERTIFYTNG PERSON <br /> Certifier iV a reprewaentative of the CUPA.RAIMrited A rrp <br /> agency.Or L1A: <br /> NAME Ol•' keRTTF1fR �; Z�:e 7sa <br /> ❑ YaNO <br /> y` NIP"of CUPA.auttt(lrised agency.or LIA: 761 <br /> TITLE OF CERTinut n� <br /> C 1• %C g( ciz� 1- If cortirter is Otho[than CUPA I L1A check appropriate box below: IQ <br /> ADDRESS rsu <br /> ❑ a Certified Irxiustrinl I{yRieniyt(CIH) <br /> ❑ b. Certified Sefaty Professional(CSP) <br /> QTS' ❑ c. Ccrtired Morine Chemist(CMC) <br /> ❑ d. keghnemd Ers romnentxl Health Speeiatkar(REBS) <br /> NE <br /> © c. Prttfaaqinnal Engir,ocr(PK) <br /> ❑ f. Cla"TI Regivated EnvimnmenW A,,tsmot <br /> DATE tiv CERTIFICATION TIMI: S' Cmin aory State Liceme Revd licensed ton(ntotor(with k,,doue <br /> substance removal certification) <br /> TA14K PRAMOUSLY HELD FLAMMABLE OR CMMBUSTIRLE MATERIALS tra <br /> ar7Q Arra d tier eo„n*t,.e A-M besed ecbd wiT a asabag hk s.Wlamw prig,,g rat teas tancoa w on rbe mk) Yes ❑ No <br /> CERTTFIER'S TANKANACI IN,4TRUCTIONS FOR SCKAP DEA eR DISPOSAL FACTLTTY,FTC; 764 <br /> L 00—CW CA /, <br /> A mpg dq+in oroatimsant y�ey Gro m4 tithe reCYc4eE/dispaatl t,u7iq ower be p,pridnt tg Poe C(irA t[lh4e is ao Ct1PA o rigx,hon tx aebmiged tg the LIA sad a,rtl,orixed <br /> ,rQ/ forn gfAe twit :nanonal caetisaor•sad the T, diR,oml Aia'1' . <br /> LIPCF(IV") 39 <br /> Formerly DTSC 1249(6/98) <br /> FILE <br /> COPY <br />