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Ah <br /> D PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> US WASTE TANK CLOSURE CERTIFICATION <br /> dl <br /> I. FACILITY IDCATION <br /> BUSUMS$NAME(some as FAcam NAw or DzA-nolq sustom Ail 3 FACII,1 PYMDO -- 1 <br /> 5fDk V - <br /> ANK OWNER NAME Tao <br /> ANK O/W''►NER ADDRESS . 741 <br /> NK OWNER.CITY SA,, Aati <br /> 742 STATE 743 ZIP CODEcy CODE ( 744 <br /> II. TANK CLOSURE TION <br /> _ Tank ID/ Concentration of Flammable Vapor Concentration of Oxygen <br /> or `me uda1° <br /> TANK dm tantmo) Top Center Top Center Bottom <br /> ) <br /> INTERIOR 745 746a 746b 7464 747a �y 747b 747e <br /> ATMOSPHERE ! �- /)0/ �/®!e <br /> READINGS. 2 749 74% 749b 74% 75na. 75% 75or <br /> 3 7517524 1 7526 7574 7534 753b 7534 <br /> M. CERTIFICATION <br /> n examination of the tank.I certify the tank is visually free from product,sludge,scale(titin,flaky residual of tank contents),rinseate and debris. I further certify <br /> that the information provided heroin is tore and accurate to the best of my knowledge. <br /> 'IGNA OF.CSTATUS OR AFFILIATION OF CERTIFYING PERSON <br /> aCertifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> O CERTIFIER (PrmW 754 Yes <br /> �GL l (� Name of CUPA,authorized agency,or LEA: 761 <br /> r(-408 <br /> TITLE OF CERTIFIER 755 <br /> 1 AL 8 If certifier is other than CUPA/LIA check appropriate box below: 762 <br /> "XDDRESS , 7s6 ❑ a. Certified industrial Hygienist(CIH) <br /> PO C 1 ti, ( ❑ b. Certified Safety Professional(CSP) <br /> 1TY 7s7 ® c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(RENS) <br /> HONE 758 ® e. Professional Engineer(PE) <br /> '12S— 2 I 0—7?) [] f. Class iI Registered Environmental Assessor <br /> g. Contractors'State License Board licensed contractor(with hazardous <br /> ATE 7ss CERTIFICATION TIME substance removal certification) <br /> o / : oo qm <br /> IANK P VIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> f yes,dw tank isnvior aunosphae dull be rcdwckod with a combust&k gas indicator prior so work being 4onduaed an dw unk.D YCs ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764 <br /> r Ti4 '�D q O -V40 �C, PO C 52—CO, <br /> 1 <br /> copy of this certificate shall aecompatty die toric to the recycling 1 disposal facility and be provided to the CUPA. If there is no CUPA,copies stall be submitted to the LIA and <br /> /operator of the tanksystem:temoval contractor•and the recycling/disposal <br /> IJPCF(12/99) 39 Formerly DISC 1249(6198) <br />