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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• LFACILITYID # I I I I I I I I I I I I I 1 ' <br /> Pl .o1i.rty J `Travel Plaza 618 1501 N . Jack 'lone Rel <br /> TANK OWNER NAME 740, <br /> Pilot Travel Centers LLC <br /> TANK OWNER ADDRESS 741 , <br /> 5508 Lonas Drive <br /> TANK OWNER CITY knoxville 742' STATE CA 743• ZIP CODE 744' <br /> IL TANK CLOSURE INFORMATION <br /> Tank ID # Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than Top Center Bottom Top Center Bottom <br /> twee tanks) <br /> TANK i ,. '; 745. .1 746a. ^s t ra 746b. 746c. 747a. _ . 7476. 747c, <br /> t c7 „ 1 <br /> INTERIOR 1 t �ir t of <br /> ATMOSPHERE Z 748, 749a, 749b. 749c. 750a, 750b, 750b, <br /> READINGS <br /> 3 751 , 7527 752b, 752c. 753x. 753b, 753b, <br /> 4 754, 754a. 754b, 754c. 755x. 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 CERTHM STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA, authorized agency, or LIA: 760 <br /> NAME OF CEItCTIFTER (Print) 7540 ❑ Yes No <br /> Name of CUPA, authorized agency, or LIA : 761 ' <br /> TITLE OF CERTIFIER 755• N/A <br /> Certified tlarine Che ;. If certifier is other than CUPA/LIA check appropriate box below: 7620 <br /> ADDRESS 756• ❑ a. Certified Industrial Hygienist (CIH) <br /> Box 2562 ❑ b. Certified Safety Professional (CSP) <br /> CITY 757• Q c. Certified Marine Chemist (CMC) <br /> lamella , CA 94501 ❑ d. Registered Environmental Health Specialist (RENS) <br /> PHONEM 758• E) e. Professional Engineer (PE) <br /> 332=Z34-6695 r/(J s 90`7 a _3tf� ❑ 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 /> � t <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.) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC. 764• <br /> Azusa Land Reclamation <br /> 1211 W . Gladstone Street TANKS/PIPING MEETS TITLE 22 REQUIREMENTS <br /> Azusa , CA 91702 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 />