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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Pae of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3. FACILITY <br />740. <br />TANK OWNER NAME <br />741, <br />TANK OWNER ADDRESS <br />TANK OWNER CITY 742. STATE 743. ZIP CODE <br />744. <br />II. TANK CLOSURE INFORMATION <br />Tank ID # Concentration of Flammable Vapor Concentration of Oxygen <br />(Attach addition: copies <br />of this page for more than Top Center Bottom Top Center Bottom <br />LANK three tanks) <br />INTERIOR 745, 746x. 746b. 746c. 747a. 7476. <br />747e. <br />I <br />ATMOSPE{ERE <br />READINGS <br />748. <br />749a. <br />7496. <br />749c. <br />7500. <br />750b. <br />750c. <br />2 <br />751 <br />752x. <br />75247 <br />752c. <br />7S3a. <br />753b, <br />753e. <br />M. 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 <br />that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />760. <br />754. ❑ Yes ® NO <br />NAME OF CERTIFIER (Print) <br />Name of CUPA, authorized agency, or LIA: <br />761. <br />TITLE OF CERTIFIER 755. N/A <br />If certifier is other than CUPA I LIA check appropriate box below: <br />762. <br />ADDRESS 736.❑ a. Certified Industrial Hygienist (CIH) <br />❑ b. Certified Safety Professional (CSP) <br />CITY 757, <br />❑ c. Certified Marine Chemist (CMC) <br />❑ d. Registered Enviromnental Health Specialist (RENS) <br />PHONE 798. ❑ e. Professional Engineer (PE) <br />❑ f Class II Registered Environmental Assessor <br />759. ❑ g. Contractors' State License Board licensed contractor (with hazardous <br />DATE CERTIFICATION TIME substance removal certification) <br />763. <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />(If yes, the tank interior atmosphere shall be re -checked with a combustible gas indicator prior to work being conducted on the tank.) ❑ Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764. <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other authorized local agency); the <br />owner andlor operator of the tank system; and the tank removal contractor. <br />UPCF HWF1249 (1/99) - 112 www.unidoes.org Rev. 02/16/00 <br />