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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS )ST <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pa1. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY DANE or DBA—Doing Business As) 3 FACILITY ID# <br /> PR 4lw�, <br /> 740 <br /> TANK OWNER NAME <br /> ]4] <br /> TANK OWNER ADDRESS <br /> TANK OWNER CITY 742 STATE y 743 ZIP CODE 744 <br /> H. TANK CLOSURE INFORMATION <br /> Q Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach addilisnal copies <br /> or this P�r1—omthan Top Center Bottom TOP Center Bottom <br /> TANK <br /> INTFRIOR 746a 7466 �? 746c 747a 747b 797c <br /> ATMOSPHERE 1 p52® 11 Com' 0 e9 <br /> READINGS 2 74a 749a 7496 749c 7509 75.0b 750c <br /> 751 752a 752b 752c 753a 753b 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 that <br /> the information provided herein is true and accurate to the best nfmy knowledge. <br /> SIGNATURE.dF r'FRTXFrcu-- STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> C/`r Certifier is a representative of the CUPA,authorized agency,or L IA: 7611 <br /> 754 <br /> !0eERTIFIERnL) El Yes No <br /> Name ofCUPA,authorized agency,orLIA_ 761 <br /> TITLE OF CERTIFIER �/ �, S 755 <br /> If certifier is outer than CUPA/LIA check appropriate box below: 762 <br /> 756 <br /> ADDRESS ❑ a. Certified Industrial Hygienist(Cllr} <br /> �© <br /> 13, Z5 ❑ b_ Certified Safety Professional(CSP) <br /> CITY 757 ❑ c. Certified Marine Chemist(CHIC) <br /> ❑ d_ Registered Environmental Health Specialist(RFH5) <br /> PRONE 'T 758 ❑ e. Pmfessionai Engineer(PE) <br /> —��� — � ❑ f Class R Registered Environmental Assessor <br /> DATE <br /> 77.59CHRTIFICATION TIME <br /> � g. Contractors'State L.ccnsc Board licensed contractor(with hazardous <br /> substance removal certification) <br /> 763 <br /> TANK PREVIOUSLY RELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (]ryes,the tank interior atmosphere shall be w-chcckod with n wrnhr stible gas indicator prior to cwrk heing muductedon the Lank.) Yes ❑ No <br /> CERTIFIER'S TAMC MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC_ 764 <br /> A copy of this certificate shall accompany the tank to the recycling I disposal facility and be provided to the CUPA_ if there is no CUPA,copies shall be submitted to the LLA and authorized <br /> aneacv.owner 1operator of the tank stem•removal contractor,and the rccyoing I disposal facility <br /> UPCF(12199) 39 Formerly DTSC 1249(6/98) <br />