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j )E antrdetas Waste Tank Own a Cer Mextior Complete and submit this page prior to snitintias any cleaning,euaing,dismantling,of excavation of a tank systan that meets.the conditions below: Any tank sysmm thn prcv*sly held a hayardous material or a heruerdote waste,treat is identified as a hawdow waste,noxi Rent Is desti>Kd to be disposed,mJaimod or closod in pleee. . This does not apply to"*systems tegnlaied under n I au&urscm Facility permit,other than pcvmit try tutu(PSR),ar t0 tank systems regulotcd under a grant of irderim stow.nor to a tart system or any portion UMV4 4 that uve m the dsRnision of scrap metol in 22 CCR 866260.10 and iv excluded form ncRulation pursuant to 22 CCR W261.6(Rx3M ReFer to 22 CCR 667383.3 and 23 CCR§2672 for disposal requi.cames lbr tank systems. iNttte= the numbering or the ingtn ct$ow follows the data elartcrn numbers shad are an the UPCF p&M- These data olernryrt nurnhen am used for daetronie ta9ma—inion and aro the xame as the numbering used in 27 CCR.Appendix,C,the Bminess Section of the Unified Program Dam Dictionary.) Pltame entmbo all psgca of yratr stdrnnitffiI. Thee halter your CUPA or Ectal agency identify wbeRter the submhW is complete and if arty pagers arc separated. 1. FACILITY 1D NUMBER-neve this blank This mMber is assigned by the CLMA. This is the unique number which identifres your fhrilily. 3. DUSMESS NAME-Ehler the Nli tiger mane or the buttines& 740. TANK OWNER NAME- Complete items 740-744,unless all itcrm we the sone as the 8usinecs tyvner 741. TAWK OWNER ADDRESS information(itcrba 111-116)on the Dttsiness.O,vperi0pbstor Identification page. 742. TANK OWNM CITY (OBS Fotm 2730).Jf the same,write'SAMF.AS SITE'otxoss this section 743. TANK OIAFMM STATE 744. TANK OW NPR ZIP CODE 745.TANK ID NUMBER 1-3-Fatter up to tlnee owner's tank W monbcn_ This is a unique number used by the w ncr to identify aha MUIL 1f sterni thin thnM tasks ate acing elwwd.awrO le odditf6nat topica of this pWm (Enter additional rink numbers in 7M and 751.) 7464 CONCENTRATION OF FI AMMASLE VAPOR 1-3-Eater three Interior l'Ittn n. le vapor Icwcis for troch tank being c103ed, taken at the lop►cermet and bosom of the tank. (Fpr more than erre lank;enter ad"onel tank readings in 744'an4 7S2,) 747.CONCENTRATION OF OXYGEN 1-3-Eater lhtre ifftlito Axygon levels for each tank being Closed,talon at the top,ccntcr. rand bomm of Ute tank. (For more than one tank,tetter etdditiottul tank readings in 75t)and 753). SIGNATURE-The business.owner or officer of the cGvapary who Is sotharizod to make dopisiphg for the facility and who hw opteratitmnt controt,shelf sign in rite spate provided 754.CER77FMt NAME-Enter the full primed atone of the low. signing on prigs 753. CFATIFTER TITLE-STftr the title of the person signing the pW 756. CERTIFIER ADURFS9-Enter the add"of the pt:rsmt siert*the pager 757. CERTIRFM CITY-Enter the city for the signer's addrmm 1 758. CERTIFIER PHONE-Ener the phone sam+bc+for Urc P--signing the pegs, 759. DATE CERTIFEFM-Enter the dart:ftl the 4ocum.cm wet signed. Emir the time thM the readinga.wete tikes. 760..CE TWM'R REPRESENTS LOCAL:AGENCY Cheek"Yes"ifthe pcnon cc tifying the pnk is a representative of the CUPA, nuthurized ogtm-,.or L IA cbcck-Nay'if rw 7151. NAME OF LOCAL AGENCY-Enter the none of the focal agency repreSdttcd by tate person certilyi"S the tank 762. AFFJLIA'nON OF CFStT1FY1N(3 PERSON.Cb=k the:cumseefim litxptga,pr oganizlS- whit h the ocreifier holds Or to which the ee"IFyiftg person belongs,ifnot a CUPA/LIA. 763.TANK HELD FLAMMABLE OR COMMISTTHLE MATERIALS-Check "Ywi-ifthe tank held flammable or cammutibte metevials, ehcak"No"'if not. 764. MANAGEMENT TNSTRUCTJON9-provide be*manaRptxatt itntpnrotions to the 3ennp dealer_disposal facility,cue.,in this space. i UPCF(12199) 40 F&Merly D'I'SC 1249(6198) FILE COPY