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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOU <br />WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />P <br />I. FACILITY IDENTIFICATION <br />or <br />BUSINESS NAME(Same as FACILM NAME or DBA -Dome Eusm"um) 3 <br />FACILITY ID# <br />r�fc%L_ 5�c4A <br />RoDo's <br />D� <br />TANK OWWN��%G `-.e.' 1'7 ✓ 4W I <br />740 <br />TANK OWNER <br />RRlI1JADDRESS <br />741 <br />TANKOWNERCITY /NLG^ .la` STATE 743 J . <br />ZBa CODE <br />II. TANK CLOSURE INFORMATION <br />Took ID # <br />(Aoaeh edmee�,t =_ <br />Concentration ofFlammable Va r <br />po <br />Concentration of Oxygen <br />TANK <br />of Chia peae for melawn <br />Iluee rinks) <br />Top Center <br />Bottom <br />Top <br />Center <br />ttom <br />ATMOSPHERE <br />1 <br />743 <br />0 7460 0 466 <br />^^ 7960 <br />t/ <br />747a <br />I <br />.: Cl 7476 <br />iG <br />"1 <br />7470 <br />READINGS <br />Z <br />748 <br />749a 7496 <br />7490 <br />750. <br />750b <br />o <br />731 <br />732. 752b <br />7520 <br />753. <br />753b <br />]S3c <br />IIT. CERTIFICATION <br />On examination of the tank, I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinsente and debris. I further <br />and accurate to the but of my knowledge. <br />the inf5?F? <br />rtity that <br />SIGNOF STATUS OR AFFILIATION OF CERTIFYING PERSON <br />I <br />t Certifierisarepruealativeofthe CUPA.authorizedacenev nrrlA• <br />760 <br />1�AtJEOF CE TIFIER (Prins) ) 730 ❑ Yes yr No <br />Name ofCUPA, authorized agency, or LIA: <br />TITLE OF C • TIFIER 753 <br />/`C��� <br />If certifier is other than CUPA / LIA check appropriate box below: <br />ADDRES 756 ❑ B. Certified Industrial Hygienist (CIH) <br />p —3 ..� 7 ❑ It. Certified SafetYProfessional (CSP) <br />CITY / � 757 Q c. Certified Marine Chemist (CMC) <br />(� � `� // 411- <br />/ rJ' / ❑ d. Registered Environmental Health Specialist (REHS) <br />PHONE - / 7s ❑ e. Professional Engineer (PE) <br />,2 c7 3a % S O / ❑ f. Class D Registered Environmental Assessor <br />DATE 739 CERTIFICAT[ON,TIhTE Contractors' State License Board licensed contractor (with hazardous <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />(Ilya, W YNr Wcmraenmplwv shell i`o . h¢ W wIN a oombwable su tndioaarpriora work being eondugedon me,..r ) �r-,� <br />CERTIFTER'S TANK MANAt;FMaTrr lve'ronrrrn�,o ____ am—Yes 0 N <br />W <br />to <br />UPCF (17199) Formerly DTSC 1249 <br />rS <br />761 <br />762 <br />