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... Company ..iVED <br />REr' ,':, <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE VIRONMEN <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICAT A' 7P r 8".ia <br />Pae of <br />1. FACILITY IDENTIFICATION <br />BUSINESS NAME (star. FA0lXYNANR.naA-regaa.in.n An 3. <br />FACILFFYRDN t. <br />/ <br />eI,e <br />TANKKJO�WNERNAME <br />I <br />TANK OWNER ADUFRESST� Ht. <br />TAAOWNERcrry S vt G" 74Z STATE �j _ 1d3' Z)PCOAL..' -;; <br />IL TANK CLOSURE INFORMATION <br />Tank ID <br />(Au1ek adduvd mPk7 <br />Concentration of Flammable Vapor Concentration of Oxygen <br />Top Centro Bottom Top Center Ilobom <br />TANK <br />urdirpye R..o.aoo <br />INTERIOR <br />ATMUBPHERR <br />74a <br />1 -4 <br />usa 746[ 7460. H7n 7476 741 <br />RRADINOS <br />2 748. <br />119x 74 h 749 75ck 7A. 75an <br />73h 7321 732a )33a )vt Rx <br />III. CERTIFICATION <br />On esmnlmNon of the tank, l certify the lank Is visually free am product, sludge, scale (then, Haky residual of lank contents), rinseate and debris 1 Further certify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a represemmive of the COPA, authorized agency, or LIA: 1m' <br />❑ Yes ® No <br />NAME OF CERTIFIER rm,,, 154' <br />/� �r�/y���G <br />Nome of CUPA, authorized agency, or LIA: i4i. <br />N/A <br />TTrLEOFCERTIFIER M <br />If certifier is other than CUPA / LIA check appropriate box below. 1az <br />❑ a certified Industrial Hygienist (CIH) <br />ADD S )54 <br />S 7 <br />❑ b. Calirted Safety Rofessioml (CSP) <br />❑ c Certified Marine Chemist (CMC) <br />CITY 751 <br />r <br />[I d. Registered Environmental Health Specialis[(KERS) <br />❑ e. Professional Engineer (Pu) <br />PHONE 1sa <br />ae <br />❑ r Class II Registered Emironmental Assessor <br />Contraclora' Sudo License Board licensed contractor (NvM haaerdoas <br />DATE <br />CERTIFICATION TIME <br />substance removal axtification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTEILEMATERIALS �S'F �1 d/C 70. <br />i <br />(Trym lM lukkNW,ia alaeolim shin ho rcriRkcd with a candWitic,% rd'orer prior b%m imN mudmNmWaud_) Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER. DISPOSAL FACILITY, ETC: <br />7:Ar,J' T(/elf/�/.uSf�' C�f'��F7� vim' f�/fT s}s✓D /S Co /S j��C>Ea o.--- <br />6£�f <br />A copy ofthh mrtificita dWI accompeoy the took m the rocycliog/d3vpoW Bcilhy and to provided . a. canny enersdni Irak clove (i.e. CUPA or other ooth.ba bot eB..YR the <br />octan endrurup. orthe rank rynerq and the tank rcr. 1coohaclm. <br />UPCF HNFI749 (1N9) - IR http:/hvsvw.anldu¢aorg Rev. 02/16MO <br />/2_ <br />AL <br />