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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE JAN 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> tNV1HUNMtN IAL HLA <br /> H <br /> I. FACILITY IDENTIFICATION BEPMT!I <br /> EKT <br /> BUSINESS NAME(Same N FACILITY NAh4E.or DBA—Doing Business As) s. FACILITYIDN I. <br /> Carpenter Co <br /> TANK OWNER NAME <br /> 740. <br /> Carpenter Co <br /> TANK OWNER ADDRESS 741. <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop 742' STATE CA 741. ZIP CODE 95330 7" <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID 4 Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than To Center Bottom To Center Bottom <br /> TANK three tanks) P P <br /> INTERIOR 1 MF 1 745. �s ® 746e, m� 7466. �' 7460. ��,7 C 747a. 47b. 747c. <br /> ATMOSPHERE {Y/ © l b 2�0-, ` 2-e e Za- F� <br /> READINGS 2 749. 749, 749b, O 749ca, 750. r` 750bp750 <br /> Q 2 j?1r . <br /> za. 8/1- <br /> 3 t. a. b. 3a 1____"`3b. 53c. <br /> III. 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 true and accurate to the best of my knowledge. <br /> SIGNATU F CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> I <br /> Certifier is a representative of the CUPA,authorized agency,or LLA: 760. <br /> 754. -1 Yes ® No <br /> NAME OF CE IDR (prin <br /> Uv C l 40-5 t. �,,,,�j-,�,s_� Name of CUPA,authorized agency,or LIA: 761' <br /> TITLE OF CUTIFIER 755. N/A <br /> 62. <br /> T / <br /> OPe-C/G �✓f CIf certifier is other than CUPA/LIA check appropriate box below: <br /> ADDRESS 756. <br /> ❑ a. Certified Industrial Hygienist(CIH) <br /> q( O( � ❑ b. Certified Safety Professional(CSP) <br /> CITY 757" <br /> ❑ a Certified Marine Chemist(CMC) <br /> ❑ It. Registered Environmental Health Specialist(BEES) <br /> PHONE 759. <br /> E],.�r/ e. Professional Engineer(PE) <br /> -707 �I L 16 ❑ f. Class II Registered Environmental Assessor <br /> DATE 159 CERTIFICATION TIME - ® g. Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> I2-7- c` Diig <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 76s. <br /> (If yes,the tai interior atmosphere shall be r checkd 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: 764. <br /> A copy of this certificate shall accompany the tank to the regclirig/disposal facility and be pmvided to the agency overseeing tank closure(i.e.CUPA or other authorized local agency); the <br /> owner and/or operator of the tank system;and the tank removal contractor. <br /> UPCF HWF1249(1/99)-1/2 - www.unidoes.org Rev.02/16/00 <br />