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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATI®N <br /> Pae of t° <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME (Same as FACILITY NAME orDBA — Doing Business As) s. FACILITY <br /> 740. <br /> TANK OWNER NAME <br /> R , <br /> 741 . <br /> TANK OWNER ADDRESS <br /> TANK OWNER CITY �, � 142. STATE 743. ZIP CODE �'�, 744. <br /> II. 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 /> TANK three tanks) <br /> INTERIOR '� 745. 746a 746b. 746c. 747a 1476. 747a <br /> ATMOSPHERE 143 <br /> READINGS 2 746. 749a 749b. 749c 750a. 750b. 750c. <br /> 751 . 752x. 752b. 752c. 753x. 7536, 753c. <br /> 3 <br /> HI. CERTIFICATION <br /> On examination of the tank, I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseate 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 STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA, authorized agency, or LIA: 760. <br /> NAME OF CERTIFIER (Print) <br /> c./" .- 754' El Yes ® No <br /> 761 . <br /> Name of CUPA, authorized agency, or LIA: <br /> TITLE OF CERTIFIER � �� to 755. N/A <br /> 40 <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 /> �� js� / ❑ d. Registered Environmental Health Specialist (REHS) <br /> PHONE 756. <br /> ❑ e. Professional Engineer (PE) <br /> C /'� �� ❑ £ Class II Registered Environmental Assessor <br /> i 759. g. Contractors' State License Board licensed contractor (with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> 763. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (If yes, the tank interior atmosphere shall be re-checked with a combustible gas indicator prior to work being conducted on the tank.) 44 Yes ❑ No <br /> CERTIFIEWS TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC : 764. <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 authorized local agency); the <br /> owner and/or operator of the tank system; and the tank removal contractor. <br /> UPCF HWF1249 (1/99) - 1/2 www. unidoes.org Rev. 02/16/00 <br />