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rv1anG Il[u'10 tl:LO:JU 1W • J.K. A)Q1pI0t uompany Jtl`J4J`JDI Ltl • L10 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE APR 12 20 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> AL <br /> 1. FACILITY IDENTIFICATION <br /> BUSNr,SSN (amupK'wy?iAmar DDA-Dftaus6 Ao 3• FACILITY Me t <br /> SUAPLOT GROWER SOLUTIONS-JACK TONE RD <br /> TANK OWNER NAME 740. <br /> J.R.SMOLOT COMPANY <br /> TANK OWNER ADDRESS 741. <br /> 7707 S.JACK TONE ROAD <br /> TANK OWNER CRY STOCKTON 141 STATE CA 943' ZIPCODE 93213 7". <br /> EL TANK CLOSURE INFORMATION <br /> Tank"ID0 Concentration ofFlammeble Vapor Concentration of Oxygen <br /> (Anee6 addN401 eaplu <br /> efVtlipege(arawredea Tap Center Bomm Top Center Bottom <br /> TANK duw tmb) <br /> 1NTbRIOA 1 DRSEL v4. .�7464 aha 9a6e cava. lam Inc <br /> ATM0.9PHSRg <br /> ggApQ,.Os Z 9490. 149°. 7N0. 1lal frac. <br /> 3 151. 93]4 C 1330. <br /> M. CERTIFICATION <br /> On examination of the Idldt I certify the lank is visually free from product sludge,ecalc(thin,flaky residual aftank contents),rinevste and debris. I Nagler certify that <br /> the infa3nation provided herein is true and accurate to the best ofmy knowledge. <br /> SIGNATURE 0 VIER / /'/ STATUS OR AFFILIATION OF C&tTIFYINO PERSON <br /> �/ •a!" Comfier is a representative ofthe COPA,mthorlad a 1°e <br /> genet',or LIA: <br /> NAME OF CERTMER le..) ❑ Yes ® No <br /> S�..,.,r �j,.,, Name ofCUPA,authorind agency,of LLA: 761' <br /> TRLB OP CERTIPMR a du rr E)2 - ST;.6 .. k t oases rr- NIA <br /> is /.e e�s•�-!' Nva e. S H 6'T v c re.+s w f If ceAiRer Is oder than CUPA l LIA shack appropriate box below: r61 <br /> Cvn T/'aCT�.t Lr a.�Sb'6 <br /> ADDRESS ❑ n. Cmifled Industrial Hygienist(CEO <br /> /'�' '3i 3 b b 6 ❑ b. Canified Safety Professional(CSP) <br /> CITY / Ar• ❑ c. Cortifiad Marine Cheteiet(CMC) <br /> n,f.rY•a le CA. 5s^ o ❑ d• RESIMmed Blniromrtental Health Specialist(RMS) <br /> PHONE !' 3' ❑ e. Pm1malonel Engineer(PE) <br /> .�..Sc�' G 4/S'-.d / �/ ❑ f. Clan n Reglsmad Eavwmnentel Amster <br /> Dore CERTMUTION TDa ® B• Contreomn'Sum License Board licensed contractor(with hnardous <br /> substance removal eoulfinudiun) <br /> ( (: 20 lfr <br /> TANK PREVIOUSLY NEID FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (0741"A kual-U'-*h'See" TabedW.4haaemhpnTbIt""AMw KW Nwh9diBvrntlu4kdanaa l4k) ❑ Ye9 ❑ Na <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACIUTY. C: 764. <br /> A copy of tide Owe"&ball agamlpsey ties Unit to On reeyeling(dispanl scanty sad be parvided to the agency owming ink ebsme(IA CUPA a ether aduvi td laeal agamyl dN <br /> ownv enNm 9panuarafaa reNrryabm;eM W audt novel cautragm. <br /> UPCF HWFIZ49(1199)-12 www.usidoa.arg PAY.016100 <br />