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iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiilI <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UPCF HWF1249 (1/99) - I/2 http://www.unidocs.or <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFRCATION <br />Page of <br />7 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same asFACILITY NAME orDBA — Doing Business As) 3. <br />FACILITY ID# <br />T <br />I <br />I. <br />SJC Household Hazardous Waste Consolidation Facilit <br />TANK OWNER NAME <br />740, <br />SJC Household Hazardous Waste Consolidation Facility <br />TANK OWNER ADDRESS <br />741, <br />7850 R A Bridgeford St <br />TANK OWNER CITY Stockton 742. <br />STATE CA 743. <br />ZIP CODE 95206 <br />744 <br />II, TANK CLOSURE INFORMATION <br />Tank ID # <br />Concentration of Flammable Vapor <br />Concentration of Oxygen <br />(Attach additional copies <br />of this page for more than <br />Top <br />Center <br />Bottom <br />Top <br />Center <br />Bottom <br />TANK <br />three tanks) <br />INTERIOR745. <br />1 <br />746a. <br />746b, <br />746c. <br />747a. <br />747b. <br />747c. <br />ATMOSPHERE <br />26917 <br />zero <br />zero <br />zero <br />N/A <br />N/A <br />N/A <br />READINGS <br />2 <br />748, <br />749a. <br />749b. <br />749c. <br />750a. <br />750b, <br />750c. <br />751. <br />752a. <br />752b. <br />752c. <br />753a. <br />753b, <br />753c. <br />3 <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 <br />that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF IF <br />IE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />760. <br />S1 <br />1 <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />❑ Yes ® No <br />NAME OF TIFIER (Print) 754. <br />Andy Bagley <br />Name of CUPA, authorized agency, or LIA: <br />N/A <br />761. <br />TITLE OF CERTIFIER 755' <br />Operations Manager <br />If certifier is other than CUPA / LIA check appropriate box below: <br />El a. Certified Industrial Hygienist (CIH) <br />762. <br />ADDRESS 756, <br />2370 Maggio Circle Ste 4 <br />❑ b. Certified Safety Professional (CSP) <br />c. Certified Marine Chemist (CMC) <br />CITY 757.❑ <br />Lodi, CA 95240 <br />El d. Registered Environmental Health Specialist (RENS) <br />e. Professional Engineer (PE) <br />PHONE 758.❑ <br />209-3674800 <br />❑ f. Class II Registered Environmental Assessor <br />® g. Contractors' State License Board licensed contractor (with hazardous <br />759. <br />DATE <br />CERTIFICATION TIME <br />substance removal certification) <br />10/05/2021 <br />2:OOPM <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 to work being conducted on the tank.) ❑ Yes ® No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764, <br />TANK ID: CONTAINMENT SOLUTIONS 500 GALLON UL -LISTED DOUBLE WALL STEEL TANK (BLACK) (RETANGULAR) (HORIZONTAL) TANK HAS BEEN TRIPPLE <br />RINSED AND READY FOR RE -USE OR DISPOSAL. TANK SHALL BE LEFT ON SITE MARKED EMPTY, READY FOR REUSE (NON-FOOD GRADE COMPATABLE <br />MATERIALS). <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); <br />the <br />owner and/or operator of the tank system; and the tank removal contractor. <br />g Rev. 02/16/00 <br />