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08/12/2002 13:19 2094683433 FIFTH FLOOR PAGE 10 <br /> N., VOA' <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> RA7A"OUS WASTE TANK CLOSURE CERTIFICATION <br /> ho of <br /> I. �1CIL1 L]�IDEN(TiFIICrtiTIODI <br /> SIISR9E55 NAM ¢anraliACittrylaAMQ JMA-noysa:—sur) <br /> TANKOWNERNAME <br /> TANKOVIMADDRFSS 74L <br /> TANK OV7NERCITY 74a. STATE " ZIP CODE 7av' <br /> - : ' :'�Yua'u CLOSURE:IN$g13MtC', 8 nw�«• <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Aexhdaitigal99Pk'a <br /> TANK 4[0omdacdun Top Center Bottom TOP Collie Bottom <br /> INTERIOR t 745. 746L 74M 749E- 7471. 747a 777e, <br /> ATMOSPHERE <br /> READINGS Z 748. 749a 7494 749c 7 75& 758c. <br /> 3 731. 73U �w R$. T93a 7$3� isle <br /> :.= -•�-� ,..: y" �. ,;all. may. � ik _- :'r�k'fi �1�ny'r: <br /> On elnminadao Of the tank,f emify the tank is visually free from produet,sludge,scale(ruin,flaky residual of tank eentents),rinseate and debris. I fardhercartify tut <br /> Ile information provided berein is tree arndaccoratc to die best of my knowtedge. <br /> SIGNATURE OF CFRTWJER STATUS OR AFFILIATION OF CERTTMiiG PERSON <br /> Certifier is a representative of the CUPA,authorized a 7b0' <br /> gettcy,or LIA,= <br /> NAME OF CERTIFIER iftw) 754 ❑ Yes ® No <br /> Name otCUPA,sutwrized agcney,or LtA: lar. <br /> TtTLEOFCERTIFMR 795' NIA <br /> Nocrtifier is other than CUPA/LIA ebxkappmpriate box below= <br /> ADDRESS 7vG ❑ a. Certified Industrial Hygimict(CIA) <br /> n b. Catilied Safety Frotessi,"(CSP) <br /> CITY 757' ❑ C. Certified Marine C hcrrd$t(CMC) <br /> ❑ d. Rcestered Edvitonnxntal Healilh Specialist(99HS) <br /> PHONE -. -. - 7a ❑ e. Professional Engineer(PE) <br /> ❑ L Class II Registcrml Environmental Assessor <br /> DATE 759. CERTIFICATION TIME ❑ g. Contractors'State License Hoard licensed cowrwtor(with hazardous <br /> substance rcnwval certification) <br /> TANK PREVIOUSLY HELD FLAMMASLS OR COMBUSTMLE MATERIAL.$ 7". <br /> pr�,e,4h.,ehi�:xhanwhthercta ha-MtAudadd,a- . as ad:>em'h*>aha,.ant adne®dan4daaaw uelc) ❑ res ❑ No <br /> CERT)FWV$TANK MANAOEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,FITC: Tat. <br /> Aeapyof"—dre Shall eh -q=y hbc Lwk w flu ncpchnVdiaposal;Mty and be prwAds6 w the ageoey we ting rank cbnve(ie.COPA er Other ahaaorized]sal agexyj: the <br /> av oe•mdoe op4eamro[au lank syahem;Bud thetan mwval canaa.�m. <br /> UPCF I>< TI249(1/99)-7[Z luttp:F/www.anidoOSArg Rev.07JI6= <br />