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'UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> P,,c of <br /> L FACILITY IDENTIFICATION <br /> BUSDqES.4NAME(S.m .FACn.rrYl4AMEor DBA-Di.gBu.Ine.MI 3 FACILFI'Y M# 1 <br /> San v'e%C4 Far& i n kon <br /> 40 <br /> TANK OWNER NAME 1 <br /> SGn V 11eTTa �AVu�Nttn �j <br /> 41 <br /> TANK OWNER ADDRESS <br /> TANKOWNERCITY `� � 142 STATE [,R 143 ZIP CODE ,s23 7" <br /> 11 TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Anach adnorrul copies <br /> TANK <br /> of this pth eeft more than Top Center Bottom Top Center Bottom <br /> INTERIORy� � 145 946a '1466746c Ola 496 , 41c <br /> ATMOSPHERE 1 vs <br /> �110 .0 a 4� <br /> it <br /> READINGS 2 948 149. 1496 149c 150a S 9 15M � 150c <br /> J 151 1528 9526 152c 153s `� 153b 953c <br /> HI. 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 We and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Al e (✓'I t V Certifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> NAME OF CERTIFIER (Not),,/ j1 954 a&Yes [I No <br /> Nrl (a of 1 a(X'4 Name of CUPA,authorizeden 961 <br /> ag cy,or LIA: <br /> TITLE OF CER FIER 155 <br /> 7� 2C H S If certifier is other than CUPA/LIA check appropriate box below: 162 <br /> ADDRESS ��,.p 156 [3a. Certified Industrial Hygienist(CIH) <br /> ;D(4' t7 W 6 6,-,, V—" c— ❑ b. Certified Safety Professional(CSP) <br /> CITY 757 El c. Certified Marine Chemist(CMC) <br /> LDi'd. Registered Environmental Health Specialist(RENS) <br /> PHONE 758 E] e. Professional Engineer(PE) <br /> Cf0�1> ��� 34 �� ❑ f Class 11 Registered Environmental Assessor <br /> 159 ❑ g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> 5(2c. <br /> 163 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (Byn,thetank interior aboosphere shall be rechecked with a cambuadble W lndiestm prior to work being conducted on the tank) 54 Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 760 <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the CUPA. If there is no CUPA,copies shall be submitted to the LLA and authorized <br /> aiscacy;owner/operator of the tanks stem:removal contractor and the recycling/disposal facility. <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />