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11/05/2B09 10:16 310523151 <br />ADAmb StKVl(:t5, 0. <br />rku p.z uc <br />UMMD PROGRAM CONSOLTDATED FORM <br />HAZARDOUS WASTE <br />RAZARDOUS WASTE TANK CLOSURE CERTMCATTON <br />I. FACILITY IDENTIFICATION <br />IFUSMESS NAME <br />t <br />lEl—Al <br />�F �L G-71 e) 151 1 <br />t <br />TANK OWNERXANK <br />0 <br />1 <br />TANK OWt6.R ADDRESS <br />lry <br />TANK OVFNER C1'fY $TATE. ) ZIP CODE ,r <br />Il. TANK CI.OSUSE INFORMATION <br />TnkIDN CD MianaFFlemtmhk Vapw Coeceatratioa DrOaygw <br />Gaea.aeNtlat "" <br />aM. rwnwe aeroTap Ca HDrm.n TDP ORhC, EDnDfi <br />TANK <br />TWORIM, ,n g a,~ ,i,. � 0 *n, <br />A l/ lig-, >7 <br />b <br />REAMAM = 6w yk 4 0 }� Q Ga gran o loans +.ra. u e J, �,m <br />mmyy <br />3 S_.,.n <br />Y/�c-}' <br />c.D ��� Ill. CERTIFICATION <br />On ewnl.tatlal oFthe tank. I u,Ti% U.e lank 15 vfaual7y nee nom pmducL altMgq awk (min. aaky .eaidlN oClank coptrAm), riMealc end dehris. r tardwr rcrtifj that <br />the infmmsnon mDNAeA herein Ia arc m.d atsWate m Me IInR Miny kenwledge. <br />SIO A CF3(TiF <br />STATUS OR AFFILIATION OF NG CERTIFYIPPRSORI <br />Cmftw i<a rCpme? Mtiw aflhe CUPA, aWnDM1DNl agency. Q L1A: ten <br />❑ Vas �.ND <br />NAmE OF - TlFipe aa. <br />Name DFCUPA, nudroriaed ag my, m LIA: rat <br />a <br />TITLE W CERTMER <br />Ifemtifimis Dthv thm COPA/ LIA chtok appmpriale bast bebw: 72 <br />Cl a CeniFmdradageiWHygieniA(CEN) <br />C /G St? � <br />ADDRESS ,n <br />❑ b. Covficd SWxq Pmf 3+i"kl (CSP) <br />❑ c. Cettifted Marine Chemisl(CMC) <br />/ >7 <br />CITY <br />�.-lo <br />( 7 <br />❑ d Regetned£an,irota..erial Resler Spedwine(REliS) <br />pmfan Mw Envi (Ps) <br />0 L Clm R Rcgiatmed Emlrt mmol A, y r <br />' .B Cmnaeton Sent Lkmm %wd licensedo mco,(wM hamdoas <br />DATE as <br />CERTIFICATION TIME <br />t..hsla.stx ranovel ccNnrmion) <br />//'�� <br />&V(7 <br />T K • IOUSLYBELOPLAmKA81.EORCOm6(1STIELEMATmAL$ <br />Ilam. drW arwrtvbslsaMmddee wiDewdumekyerhklew Mbb�T Fl4eaoMusted e. Detnk) Yan ❑ Na <br />CERTrFIEJ�R'�STlANK�l/d ANACI _IN/$TAUCrip113 FOR SCNAP OEA EIL DISPOSAL FACiLTrY, ETC: '+at <br />A mayoftho n+PNas aem.spmtyapatekte meydag�dLpsY aimSy enders p,wNeA ftibeSUFAClfdvahne dJPAmPws Ywlhatbmitud to aeLlAYdsuBmised <br />tray a..m I eraeteh emn.ator tend t oto <br />UPCP (12199) 39 <br />Formerly DTSC 1249 (6M) <br />