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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pea of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME fsame as FACILITY NAME or DBA-Doing Business As) 3 FACILITY W# 1 <br /> Q <br /> TANK O NER NAME ( ]°o <br /> TANK OWNE11 ADDRESS 741 <br /> 24ks tAeUt^1ti& Tag <br /> TANK OWNER CITY141 1 <br /> y STATE /� ]43 ZIPCODE 1°0 <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (AnacA sddlnonnl copies <br /> anMe me�N <br /> TANK rce laoks) Top Center Bottom Top Center Bottom <br /> INTERIORI ]a5 )°an ]°[,b 74k 747a v4]b ]ah <br /> ATMOSPHERE <br /> READINGS Z ]aa 749a 749b ]avc ]5(Ia ]Sob ]Sac <br /> 3 751 752a 7526 753c 153a 7536 753c <br /> III. CERTIFICATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank contents),rinseate and debris. I further certify that <br /> the information provided herein is true and accurate to the best crony knowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative ofthe CUPA,authorized agency,or LIA: ]w <br /> NAME OF CERTIFIER (PnnD 754 <br /> ❑ Yes ❑ No <br /> Name of CUPA,authorized agency,or LIA: 61 <br /> TITLE OF CERTIFIER 755 <br /> If certifier is other than CUPA/LIA check appropriate box below: ]u <br /> ADDRESS 15e <br /> ❑ a Certified Industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CSP) <br /> CITY ]5] <br /> ❑ o Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE ]5tl <br /> ❑ e. Professional Engineer(PE) <br /> ❑ f Class Il Registered Environmental Assessor <br /> ]Sv [s]g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS tw <br /> (Ifya,Netank 1nhena1.11here slut be rechecked u'uhawmbsisabio,sa iodicslorpnor to work being conducted on the rank.) ❑ Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: ]sa <br /> A copy ofthis mitificate shall accompany the tank to the recycling/disposal facility and be provided to the CUPA. Ifthere is no CUPA,copies shall be submitted to the LIA rind authorized <br /> no 'owner/operator ofthe tank systern,-rerrrova]contractor'and the re,daig/disposal facili . <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />