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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION' <br /> -F- 1 <br /> Pao of <br /> I. FACILITY IDENTIFICATION <br /> BUSMESSNAME(Same u*rACrLrrvNAm9^r DBA-Doing Husineu As) -3-FA-ClI 11T1 <br /> LITY ID# 1 <br /> TANK OWNF.k NAnsc <br /> f 1 <br /> TANK OWNER ADDRESS / 741 <br /> TANK OWNER CITY3 <br /> g <br /> c STATE �= ZIP CODEG 3 <br /> II. TANK CLOSURE INFO TION <br /> Tank on # Concentration of Flammable Vapor(Attach additional copies Concentration of Oxygen <br /> of this pago for more than <br /> TANK throe W&s) Too Center Bottom Top Center Bottom <br /> INTERIOR 1 �' 745 746a 746b 7466 747a 747b 747e <br /> ATMOSPHERE <br /> READINGS 2 748 749a 749b 749c 750a 750b 750c <br /> 3 751 7524 752b 752c 753a 753b 7570 <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),rinseate and debris. I further certify.that <br /> the information provided h in is true and accurate to the best of my knowledge. <br /> SIGNATURE OF TIFIFR STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> 'L—ex Certifier is a representative of the CUPA,authorized agency,or LIA: 760OF CE TIFIER (Print) 754 <br /> ❑ Yes No <br /> yes. Name of CUPA,authorized agency,or LIA: 76t <br /> TITLE OP C TIFIER 755 <br /> If certifier is other than CUPA/LIA check appropriate box below: 762 <br /> ADDRES 756 <br /> �.ry Lam' E] a. Certified Industria!Hygienist(CIH) <br /> 7V 3-.J 7 ❑ b. Certified Safety Professional(CSP) <br /> CITY 757 Q c. Certified Marine Chemist(CMC) <br /> 'v" J 6_ 1 ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE �/ 75 ❑ e. Professional Engineer(PE) <br /> C/ � / ❑ f. Class N Registered Environmental Assessor <br /> 759 Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFIGATION.1'IIvFE <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS jauthorized <br /> (Ifyes,the tankituerioretmosph=shall berochxkcdwith acombustiblegasindicator prior to work being conducted onthe tank.) Yes ❑ NO <br /> CERTIFIER°S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: . <br /> A copy.of this c rate shall accompany the tank to the recycling/disposal facility and be provided to the CUPA. If there Is no CUPA,copies shalt be submitted to the LI <br /> a enc •owner/o erator of the tanksystem;removal contractor and the rcc clin /tl osal facility. <br /> Formerly DTSC 1249(6/98) <br />