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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) I FACILITY ID# <br />TANK OWNER NAME <br />740. <br />TANK OWNER ADDRESS <br />741_ <br />TANK OWNER CITY 742 STATE 743- <br />ZIP CODE <br />744. <br />II. TANK CLOSURE INFORMATION <br />Tank ID 4 <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />(Attach additional copies <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />of this pirrtanks) =a <br />INTERIORl <br />745. <br />746& <br />746b. <br />7460 <br />747x, <br />747b. <br />747c. <br />ATMOSPHERE <br />READINGS <br />2 <br />748. <br />749a <br />749b. <br />749c. <br />750& <br />75W <br />750c- <br />3 <br />751. <br />j 752& <br />752b. <br />752c. <br />753a. <br />753b, <br />753c, <br />III. CERTIFICATION <br />On examination ofthe tank, I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseate and debris. 1 further certify <br />that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />11 Yes ®No <br />760, <br />NAME OF CERTIFIER (Print) 754. <br />Name of CUPA, authorized agency, or LIA: <br />N/A <br />761. <br />TITLE OF CERTIFIER 753. <br />If certifier is other than CUPA / LIA check appropriate boa below: <br />a. Certified Industrial Hygienist (CIH) <br />762, <br />ADDRESS 756.❑ <br />❑ b. Certified Safety Professional (CSP) <br />El c. Certified Marine Chemist (CMC) <br />CITY 757. <br />❑ d. Registered Environmental Health Specialist(REHS) <br />e. Professional Engineer (PE) <br />PHONE 758.0 <br />❑ 1r. Class II Registered Environmental Assessor <br />El g. Contractors' State License Board licensed contractor (with hazardous <br />759. <br />DATE <br />CERTIFICATION TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />763 <br />(If yes, the tank interior atmosphere shall be re-checked with a combustible gas indicator prior w work being conducted on the tank.) ❑ Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />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 (1199) -1/2 www.unidoCLorg Rev. 02/16/00 <br />