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' EGEIVEL <br /> UNIFIEDPROGRWCONSOLIDATEDFORM AUG 10 2015 <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERIgO fPROMENTAI. <br /> yChITL1 r)CDagTtaChIT <br /> /77 Pe C of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(3w*wPACWTNAML'wD0A-Dchg& l%*w Ar) J. FACILIIV IDg 1. <br /> l.4T�/ i - .v7 fir' f s <br /> 2Z 9 <br /> TANKOWNER NAME iNt <br /> TANK OWNER ADDRESS ....—_— 741. <br /> 9,�ot5 I'leV <br /> TANK OWNER CITY S �L/� ]aa STATE C ]" ZIP CODE: <br /> �szo _ "' <br /> II. TANK CLOSURE INFORMATION <br /> Teak IDA Concentration k.01- ofFTammable Vapor(Aasabsddmaks Por Concentration of Oxygen <br /> WtliFae.re aim <br /> TANK Top Center Bottom Top Center Bottom <br /> rbmm,b) <br /> INfPRIOR I ]15. �.` ]�16a IJah ]Jco. f�,.�ia -�NJb. �y� laic <br /> AtMOSPHERO V <br /> READINGS Z ]as, 74W. ---- N4h. O ]i9c ]5fR r ]5nh ]5na <br /> nza risk 75:c ]5]a. (.J• z. CJ Z <br /> ]Ah iSJe <br /> HI. CERTIFICATION <br /> On examination ofthe tank,l certify the tank is visually free from product;sludge,scale(thin,flaky residual of lank contents),rinseate and debris I furthercertify that <br /> the infunoation Provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE 0 T7 STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier iso representative of the CUPA,authorized agency, TM <br /> g ncy,or LIA: <br /> N OFC TIPIER rhwa ]H' ❑ Yes 0 No <br /> M. <br /> TITLE <br /> •f,//'� - Name ofCUPA,authorized agency,or LIA: <br /> TITLE OF CERTIFIER J ]ss. N/A <br /> Ifcertifrw is 0111"than CUPA/LTA check appropriatew..bon below. ]s' <br /> ADDRESS ]N. <br /> ❑ a Certified Industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CS11) <br /> CITY ]5]. <br /> ❑ a Certified Marine Chemist(CMC) <br /> J C �/ ❑ d. Registered Environmental Health Specialist(KERS) <br /> PHONE ]sa <br /> �I ❑ e. Profeuionel Engineer(PE) <br /> of — 7 ❑��f" Class 11 Registered Environmental Asscssor <br /> DATE / MCERTIFTCATION TIME Contractors'Stale License Board licensed eontractof(with hazardous <br /> p� substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLfi MATERIALS To <br /> (IrJ'K derut4bbsbmrpinvsbdlGnrAasnl wilbsmnbW@Ic ae krliorarpiorb.rat sena madurlelmlhsuik) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEbtEN'1'INST'RUCT'IONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: i61, <br /> T-YVAr S Tai�ct eiasFu� coz y leeef �01C <br /> � <br /> /iUUO�C E # r3 q3� <br /> K A; <br /> A oopy afrbu mdiRemo sh0 geanpetry de Oak b the rteycliaj•JMepmd 9e0i1Y and be pmvided to Ib agorwy o5emednµIrak clams(ia CUPA a whwauthwizt\i bol. re <br /> Yt <br /> qod Mrhe <br /> ower andlw opwerwofPoe bvk syrtwnod tank rclwah.Nw. 8' k <br /> UPCF H1VpUA9(1/99)-1/3 hftp://mm.unidoc&org Rev.02/16/00 <br />