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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Page of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(S.as FACWTY NAME.DBA-Wing Bueinnr Ar) 3. FACILITY ID# 1. <br /> Rots1 ,l YL. <br /> TANK OWNER NAME 740. <br /> TANK OWNER ADDRESS 741' <br /> e <br /> TANK OWNER CITY 741' STATE CA <br /> 741. ZIP CODE 3 _/ 744. <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Mtach ddaunat copks <br /> TANK <br /> pett uva�t� Top Center Bottom Top Center Bottom <br /> INTERIOR1 �� 745. W6a 7466. 7a6c. 747a 706 ]4]e. <br /> ATMOSPHERE <br /> READINGS 2 748. 749 7496 74%. 750a 750h 75ac. <br /> 3 751. 752. 7526 732c. 753a 7536. 733c. <br /> HI. CERTIFICATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,(laky 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 /> SIGNATU C IE STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 76o <br /> AME OF CERTIFIER _(PW) y M. ❑ Yes ® No <br /> d AL, Llf"ril. Name of CUPA,authorized agency,or LIA: 761' <br /> TITLE OF CERTIFIER 735' N/A <br /> A 5i9Cr_,1,A �`'z� If certifier is other than CUPA/LIA check appropriate box below: 76-. <br /> ADDRESS 736 ❑ a. Certified Industrial Hygienist(CBI) <br /> 3 /a � *` C ❑ b. Certified Safety Professional(CSP) <br /> CITY,/'� / pp 757 ❑ c. Certified Marine Chemist(CMC) <br /> /,Q ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 754. <br /> 759. ❑ e. Professional Engineer(PE) <br /> (/ 62) ��,�—��� f Class II Registered Environmental Assessor <br /> 759. g. Contractors State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME <br /> substance removal certification) <br /> . 1221 <br /> o3 1 //.60 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 76.1. <br /> (If yet,die tart interior atrrmpbne shalt be«<heekd with a aondwnible W indiati r priorro w.k Was eadundm the tads) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: D, ^Aiv rL 1--- <br /> A <br /> _A copy of this certificate shall accompany the tank to the tecycling/disposal facility and be provided to the agemy overseeing unk clonae(i.e.CUPA or other authorized local agency): the <br /> owner and/or operator of the tank systene and the tank removal contractor. <br /> UPCF H W F1249(1/99)-1/2 http://w".unidoes.org Rev.02/16/00 <br />