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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> P.m f <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(58anaFAc[r.17YB Eer OHA-Doing BasWwAs) 3FACILITY IDI1 1 <br /> :: 4!-G Z- Gv 7- <br /> TANK OWNER NAME 171 Q /C £slig S ��glFis- 740 <br /> TANK OWNER ADDRESS T41 <br /> 30 UJ �_ <br /> TANK OWNER CITY f01 STATE 2'5 73 Zfla CODE t4 <br /> S/2Z <br /> IL TANK CLOSURE INFORMATION <br /> Tank IDM ConcentretionofFlammab]eV <br /> (A¢raID WNe• aPor Concentration of Oxygen <br /> ¢feiupege fucas) dun <br /> Tdam wb) Top Center Bottom Top Center Bottom <br /> TNI'MUOR <br /> ATMOSPHERE i AS ---7T6—. 796¢ 7478 747b7qc <br /> READINGS Z / 748 7498 7998 7 9e 7508 7506 750c <br /> 3 751 ]Sh ]526 ]52c ] a ]376 753c <br /> U00 M. CERTIFICATION_ . <br /> On examination orthe 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 h ' is true and aocm m to the best ofmy knowledge <br /> SIGNATURE OF TH IPR STATUS OR AFFILIATION OP CERTIFYING PERSON <br /> Z, I Cenifler is a represenlative of the CUPA,authorized agency,or LIA: 960 <br /> OF CE TIFIER oP ko 7N <br /> ❑ Yes AN. <br /> Name of CUPA,authorized agency,or LIA: 761 <br /> TITLE OFC TTPIER 7 <br /> If certifier I9 other than CUPA/LIA check appropriate box below: 762 <br /> ADORES � !� 736 El a. Certified Industrial Hygienist(CIH) <br /> o \/ 'j/ J✓ 7 0 b. Certified Safety Professional(CSP) <br /> CITY C '� r 731 4 c. Certified Marine Chemist(CMC) <br /> `�JJ <br /> ze" <74 / ❑ d. Registered Enviro�lental Health Specialist(REHS) <br /> PHONE / ❑ e. Professionul P.ngineer(PE) <br /> © C7 J-2 C), S ((�/ <br /> DATE 759 13on <br /> E Class R Registered Fr virmental Assessor <br /> CERTIFICATION TIME Ork Contractors'Stine License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> pryeA aY unl:Wvimeaampi cAdwM.ccbfibleguhdkampiocawohbdagoendieaa onNa aNe) <br /> CERThTER•S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DLSPOSAL FACILr1Y,ETC; Yur p No 764 <br /> A copyof thl8 catuleate eluR xcompeoy the took to the m c)iag/dhp¢wl factliry and be govided 10 th¢CUPA, ffihcre 4 ae CUPA,topica shell be submitted to the LIA cud authorized <br /> amt ow¢a/ tor ofthetaks mmremoval contractor mdthe ciln /di nl ficili . <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />