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UNIFIED PROGRAM CONSOLIDATED FORM <br /> B[A.7ARD0US WASTE <br /> HAZARDOUS WASTE TANK CLOSURE C ERTMCATYON <br /> i <br /> Pae of y <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME(Seas FACtttrstNat+18nrpnA-noinglivaawAs) 3 FACILITY MY t <br /> 740, <br /> TANKOWNERNAME <br /> i <br /> TANK OWNER ADDRESS 741. <br /> TANK 0 WNER CITY ��� 742 STATE 743. yIp CODE S Z Q 74t, <br /> IL TANK CLOSURE INFORMATION <br /> TankID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of"f6wtfor morethao Top Center Bottom Top Ccnter Bottom <br /> TANK stveo ks) <br /> INTERIOR I 745, 746L 746b. 7460 747a 747b. 747c. j <br /> ATMOSPHERE <br /> READINGS 2 748. 749x. 7496. 749e 750x 7501,. 750c. <br /> 7S t. 752x. 7526. 7520. 753 a. 753b. 753 c. <br /> 3 <br /> On examination of the tank,I certify the tank is visuatiy free from product,sludge,scale(thin,flaky residual of tank contents),rinseate and debris. I further certify that <br /> the arformation providgd herein is true and accurate to the best of my knowledge, f ' t�✓R Z0/`/ %7 <br /> SIGNATURE OF CERTIFIER• STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is arepresentativeofthe CUPA,authori2edagency,orLIA: -,- <br /> NAME OF CERTIFIER (pa-t) ,/*f pt%/nf 7 i � 754. ❑ Yes ® No <br /> ore rive. _ <br /> Name ofCUPA,authdrized agency,or LIA: <br /> z 76t <br /> TITLE OF CERTIFIER f ff/�ir'¢/Ll��ys 755 N/A <br /> If certifier is other than CUPA I LIA check appropriate box below: 76z'' <br /> ADDRESS 756. 0 a. Certified Industrial Hygienist(CIH) <br /> 12 2`l ❑ b., Certified Safety Professional(CSP) <br /> CITY 757• ❑ e. Certified Marine Chemist(CMC) <br /> 0/0 ❑ d Registered Environmental Health Specialist(RENS) <br /> PHONE P• 758. ❑ e. Professional Engineer(PE) <br /> ❑ f. Class II Registered Environmental Assessor <br /> 759. 8 Contractors'State License Board licensed contractor(with l` <br /> DATE CERTIFICATION TIME �f substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (if yes,the tank inLenor armosphmshali be m-Lbrelbd vlth a carnbusliblops indicator prior to immic being conducted an the tw&) Z'tS ❑ 11( <br /> CERTIFIEWS TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: <br /> A copy of this certificate shall accompany the tank to the recycling/dispoW facility and be provided to the agency overseeing tank closure(i.e.CUPA or o" <br /> owner and/or operator of the tante system;and the tank removal contractor. <br /> UPCF HNVF1249(1199)-112 www.unidues.org <br />