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at <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE JAN 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> ENVIRONMENTALUFAL H <br /> DEP WM,ENT <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACTUTYN.AkE or DBA-Doing Business.As) FACILITYIDH I. <br /> Carpenter Co <br /> TANK OWNER NAME 740, <br /> Carpenter Co <br /> TANK OWNER ADDRESS 741, <br /> 17100 South Harlan Road <br /> TANK OWNER CITYLathrop 742. STATE CA 743. ZIP CODE 95330 744 <br /> II. TANK CLOSURE INFORMATION <br /> Tank IDH o . . __-.- - <br /> Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> onhis page for more than To Center Bottom To Center Bottom <br /> TANK three tanks) P P <br /> INTERIOR 745, 746, 746b 746c. 747a. r� 747b, p 747c. <br /> ATMOSPHERE 1 O 2C7, r{7 <Os tz c <br /> READINGS ]4E. ]49a. ]496 7490 750a. ]506. 750c. <br /> — ---- .. --- z I 0 c�. lb 2 . `o E�) <br /> 3 751. 732e. 7526. 82c. � 753e 753b. 753c - -- - <br /> v, Y, � <br /> III. CERTIFICATION <br /> _n_ <br /> Oexamination of the tank,Ybertify the tank is visually free from'p}odtici;sludge;shale(thin;flaky7e3idual of tankdonteiits),ririseaie addHetiiis.-ITuRhef certify"tlisC <br /> ... .. .Ihe information provided bereinis true and accurately_[he best of my knowledge. . . _ . - <br /> .' —.SIGNA 'OF CPRTIFIER --- - - - -- - TATUS OR-AFFILIATION OF-CER=-- - NG-PERSON "----.----- - <br /> Certifier is representative of the CUPA,authorized agency,or LIA: _ 760. <br /> NA`MIEEOF C IFIER (pdm) f 754. ❑ Yes ® No <br /> Name of CUPA,authorized agency,or LIA ]61. <br /> TITLE OF CE FIER 755. N/A _ <br /> PG C_j If certifier is other than CUPA/LIA check appropriate box below: - 762_ <br /> ADDRESS 7561 ❑ a. Certified Industrial Hygienist(CIH) <br /> wO! ❑ b. Certified Safety Professional(CSP) <br /> CITY 7n. ❑ c. Certified Marine Chemist(CMC) <br /> i <br /> `Gi ❑ d. Registered Environmental Health Specialist(RENS) <br /> - , <br /> PHONE vs ❑ e. Professional Engineer(PE) <br /> 70'7 �� o- ❑ f. Class 11 Registered Environmental Assessor <br /> i <br /> DATE <br /> ;7]11CERTIFICATION TIME g Contractors'State License Board licensed contractor(with hazardous I <br /> substance removal certification) <br /> pq <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS - 763. <br /> (I(yes.the tank interior atmosphere shall be rechecked with a combustible gas indicator prior to twrk belna conducted on the tank.) ❑ Yes ® No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER.DISPOSAL FACILITY,ETC: 764. <br /> A copy of this ccniftale shall accompany the lank to the recycling/disposal facilitc and be provided to Ihe agency overseeing lank closure(i.e.CUPA or other authorized local aeenev): Ihe <br /> owner anNor operator of[lie lank syslem:and(lie tank ILnovaI contmcl or. <br /> UPCF HWFI249(1/99)-1/2 u'Stw.inidocs.oig - Rev.02/16/00 <br />