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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 /> BUSINESS NAME (same as FACILITY NAME or DBA — Doing Business As) 3. FACILITY ID # 1 . <br /> Fl yf ncr! J Trr . ' Fel Plaza 618 <br /> TANK OWNER NAME 740. <br /> " I.ok Trnivti. l (`, enters LLC <br /> TANK OWNER ADDRESS 741 ' <br /> Wig forns Drive <br /> TANK OWNER CITY 742. STATE 743• ZIP CODE 744, <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID # Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than P <br /> three tanks) To Center Bottom Top Center Bottom <br /> TANK 745. 746a. 746b, 746c. 747a. 747b, 747c. <br /> INTERIOR I <br /> ATMOSPHERE 2 748. 749a. 749b, 749c. 750x. 750b. 750b, <br /> READINGS <br /> 3 751 , 752a. 752b, 752c. 753a. 753b, 753b. <br /> 4 754. 754a. 754b, 754c. 755a. 755b, 755b. <br /> III, CERTIFICATION <br /> On examination of the tank, I certify the tank is visually free from product, sludge, scale (thin , flaky residual of tank contents), rinsate and debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA, authorized agency, or LIA : 760, <br /> NAME OF CERTIFIER (Print) 754• ❑ Yes No <br /> Name of CUPA , authorized agency, or LIA: 761 • <br /> TITLE OF CERTIFIER 7554 N/A <br /> If certifier is other than CUPA/LIA check appropriate box below: 762 • <br /> ADDRESS 756• ❑ a. Certified Industrial Hygienist (CIH) <br /> ❑ b. Certified Safety Professional (CSP) <br /> CITY 757• ❑ c . Certified Marine Chemist (CMC) <br /> ❑ d . Registered Environmental Health Specialist (REHS) <br /> PHONE 758. ❑ e. Professional Engineer (PE) <br /> ? 7 ^ 29 �^fit}5 ❑ f. Class II Registered Environmental Assessor <br /> DATE ` 759• CERTIFICATION TIME ❑ g. Contractors ' State License Board licensed contractor (with <br /> hazardous substance removal certification .) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (If yes, the tank interior atmosphere shall be re-checked with a combustible gas indicator prior to work being completed on the tank.) X Yes ❑ No <br /> CERTIFIER ' S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER , DISPOSAL FACILITY, ETC . 764. <br /> I bi ; laul:. LeC t TANKS/PIPING MEETS TITLE 22 REQUIREMENTS <br /> CRUSH WITH HEAVY EQUIPMENT <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other <br /> authorized local agency) ; the owner and/or operator of the tank system; and the tank removal contractor. <br />