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UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />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)3 FACILITY ID# <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />1 <br /> <br />TANK OWNER NAME 740 <br /> <br />TANK OWNER ADDRESS 741 <br /> <br />TANK OWNER CITY 742 STATE 743 ZIP CODE 744 <br />II. TANK CLOSURE INFORMATION <br />Concentration of Flammable Vapor Concentration of OxygenTank ID # <br />(Attach additional copies <br />of this page for more than <br />three tanks)Top Center Bottom Top Center Bottom <br />1 745 746a 746b 746c 747a 747b 747c <br />2 748 749a 749b 749c 750a 750b 750c <br />TANK <br />INTERIOR <br />ATMOSPHERE <br />READINGS <br />3 751 752a 752b 752c 753a 753b 753c <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 of my knowledge. <br />SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA:760 <br />NAME OF CERTIFIER (Print) <br />754 Yes No <br /> Name of CUPA, authorized agency, or LIA:761 <br />TITLE OF CERTIFIER 755 <br /> If certifier is other than CUPA / LIA check appropriate box below:762 <br />ADDRESS 756 a. Certified Industrial Hygienist (CIH) <br /> b. Certified Safety Professional (CSP) <br />CITY 757 c. Certified Marine Chemist (CMC) <br /> d. Registered Environmental Health Specialist (REHS) <br />PHONE 758 e. Professional Engineer (PE) <br /> f. Class II Registered Environmental Assessor <br />DATE <br />759 <br />CERTIFICATION TIME g. Contractors’ State License Board licensed contractor (with hazardous <br /> substance removal certification) <br /> <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 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 /> <br /> 764 <br />A copy of this certificate shall accompany the tank to the recycling / disposal facility and be provided to the CUPA. If there is no CUPA, copies shall be submitted to the LIA and authorized <br />agency; owner / operator of the tank system; removal contractor; and the recycling / disposal facility.