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Hazardou'3 Waste Tank Closure Certification Instructions Complete and submit this page after cleaning any underground or aboveground tank system subject to Title 22, Division 4,5, Chapter 32, California Code of Regulations. Refer to 22 CCR §67383.3 and 23 CCR §2672 for disposal requirements for tank systems. Completed Unified Program Consolidated Form (UPCF) Business Activities and Business Owner/Operator Identification (OES Form 2730) pages must be submitted with this form. Please number all pages of your submittal. (Note: Numbering of the following instructions follows the UPCF data element numbers on this form.) I . FACILITY ID NUMBER - This number is for agency use only. Leave this space blank. 3. BUSINESS NAME - Enter the complete Facility Name. 740. TANK OWNER NAME - Complete items 740-744 unless all items are the same as the Business Owner information (items 741. TANK OWNER ADDRESS - 111-116) on the Business Owner/Operator Identification page (OES Form 2730). If the same, 742. TANK OWNER CITY - write "SAME AS SITE" across this section. 743. TANK OWNER STATE - 744. TANK OWNER ZIP CODE - 745. TANK ID NUMBER 1-3 - Enter up to three owner tank ID numbers. These are unique numbers used by the owner to identify each tank. If more than three tanks are being closed, complete additional copies of this page. (Enter additional tank numbers in 748 and 751.) 746. CONCENTRATION OF FLAMMABLE VAPOR 1-3 - Enter interior flammable vapor concentration readings taken at the top, center, and bottom of the tank. (If more than one tank, enter additional tank readings in 749 and 752.) 747. CONCENTRATION OF OXYGEN 1-3 - Enter interior oxygen readings taken at the top, center, and bottom of the tank. (If more than one tank, enter additional tank readings in 750 and 753). SIGNATURE - A qualified professional meeting the requirements of 22 CCR §67383.3(f) shall sign in the space provided to certify that the cleaned tank(s) meet all standards specified in 22 CCR §67383.3(c)(1) and (2). 754. CERTIFIER NAME - Print or type the fill name of the person signing the Certification. 755. CERTIFIER TITLE - Enter the title of the person signing the Certification. 756. CERTIFIER ADDRESS - Enter the address of the person signing the Certification. 757. CERTIFIER CITY - Enter the city for the signer's address. 758. CERTIFIER PHONE - Enter the phone number for the person signing the Certification. 759. DATE CERTIFIED - Enter the date that the Certification was signed. Enter the time that the readings were taken. 760. CERTIFIER REPRESENTS LOCAL AGENCY - Check "Yes" if the person certifying the tank is a representative of a CUPA or authorized local agency, otherwise, check "No." 761. NAME OF LOCAL AGENCY - If certified by a CUPA or other local agency, enter the name of the agency. 762. AFFILIATION OF CERTIFYING PERSON - Check the certification, license, or organization which the certifier holds or to which the certifying person belongs, if not a CUPA or other local agency. 763. TANK HELD FLAMMABLE OR COMBUSTIBLE MATERIALS - Check "Yes" if the tank(s) previously held flammable or combustible materials, otherwise check "No." 764. MANAGEMENT INSTRUCTIONS - Provide tank management instructions to the scrap dealer, disposal facility, etc. in this space. UPCF HWF1249 (1/99) - 212 www.unidocs.org Rev. 02/16/00