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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Page Of <br />I. FACILITY IDENTIFICATION <br />BUSMSS NAME (Saine, as FACILITY NAME or DBA - Doing Business As) 3. FACILITY ID# <br />I. <br />�e.A ye11w1-ek12b'1Wt?1A0L61"&Y-,' <br />TANK OWNERNAME e,-) <br />-61 <br />740. <br />M&MV nVINFR ADDRESS <br />741. <br />TANK OWNER CITY ael - Md r e, 742, STATE 743. <br />ZIP CODE <br />744. <br />11. TANK CLOSURE INFORMATION <br />Tank ID <br />Concertation of larnmable Vapor <br />CortcentrationofOxygen <br />(Attach additional copies <br />TOP <br />Center Bottom <br />TOP <br />Center <br />Bottom <br />ofthispagelmmorethem <br />TANK <br />itueetanks) <br />INTERIOR <br />® . 745 <br />746a. <br />7461L 746r- <br />747a. <br />747b. <br />747c. <br />ATMOSPHERE <br />I <br />749a. <br />749b. 749c, <br />750a. <br />7506. <br />750c. <br />READINGS <br />2 <br />148. <br />3 <br />751, <br />752a. <br />752b. 752c- <br />153.1 <br />753b. <br />7530. <br />III. CERTIFICATION <br />On examination of the tank, I certify the tank is visually free from product, sludge, scale (thin, flaky residual oftank contents), residual and debris. I further certify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERT*,,nNGPERSON <br />Ccrffw is a representative of the CUP A, authorized agency, or LIA: <br />13 Yes c3 No <br />760. <br />NAAN OF CERTIFIER (Print) 754. <br />Nam of CUP A, aulhonzed agency, or LIA.- <br />N/A <br />761. <br />TITLE OF CERTIFIER 755. <br />If certifier is other than CUP A I LIA check appropriate box below: <br />C3 a. Certified Industrial Hygienist (CHI) <br />762. <br />ADDRESS 756. <br />0 b. Certified Safi" Professional (CSP) <br />Do. Certified Marine Chemist (CMC) <br />CITY 757. <br />0 d. Registered Environmental Health Specialist (REHS) <br />C3 e. Professional Engineer (PE) <br />PHONE 758. <br />13 C CI= H Registered Environmental Assessor <br />0 g. Contractors State Lumnse Board licensed conlrador (with hazardous <br />759. <br />DATE <br />CERTIFICATION TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR, COMBUSTIBLE MATERIALS <br />763. <br />(IfYes, the tank interior atmosphere shall be re -checked with a conibustihie gas indicator prior to wozk being conducted on the tank) Yes E3 No <br />CERTWIER!S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764. <br />A copy ofthis certificate shall accompany the tank to the recyc1mg/itsposal facility and be provided to the agency oveiseeing tank closure (Le. CUPA or other authorized local agency); the <br />owner and/or operator ofthe tank system; and the tank removal coubactor. <br />