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P FrIFIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE JAN 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> ENVIRONMENTAL HEALT <br /> -�. E <br /> Paoe I of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY RAS or DBA-Doing Business Asa FACILITY IDq 1. <br /> Carpenter Co <br /> TANK OWNER NAME 740. <br /> Carpenter Co <br /> TANK OWNER ADDRESS 741_ <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop "�STATE CA ]91 ZIP CODE 95330 744. <br /> II. TANK CLOSURE INFORMATION <br /> Tank IDH ._ _. lam <br /> Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> Donis page for are man To Center Bottom To Center Bottom <br /> TANK mrec ranks) P P <br /> INTERIOR 745 . 746b. 746c747a. 747 � 747< <br /> ATMOSPHERE I b^ 3 • 10 2— JLt CAaq . <br /> READINGS V� 74a. 749a. 749b, 749c. 1� �]50a. 7506. 750c. <br /> 2 1 V �.'`6 00,15 <br /> J ��]51. �3^ ]Sla, 1526. ]52c `]53a. C^. fj]53b. �75;c. <br /> // CERTIFICATION <br /> On examination of the tank,I certifythe tank is 6isuah free h*tim rdduc�31ud e,sczle tfiiri;M����residual iiftank'coBieri[s,nnseaft:ividde6iiE:'ICiirthef-Czrti that ' <br /> . y ...P.. � ..g .. ( aky ). _.. _.. <br /> .. .. .. .the information prpvided.I3ere p_is true and accurate[p the best of my I:nowledge. <br /> -SIGNAT OF CE TIER. _.___.__ STA-TUS-0R-AFFILIATION OF-C€RT3FYING-P€RSON -- -.- ---= --- <br /> 760. <br /> - - --- - --Certifier is-a representative of the CUPA;authorized agency,or LIA: - <br /> .. .NAME OF CERTgIER Lmnt) 754. ❑ Yes ® No <br /> (,7J <br /> 1A-J' �.L Name of CUPA,authorized agency,or LIA: .76I. <br /> v 1 <br /> TITLE OFERTIFIER 2 755. N/A <br /> If certifier is other than CUPA/LIA check appropriate box below: 760. <br /> ADDRESS 756. ❑ a. Certified Industrial Hygienist(CIH) <br /> p �eJ..re yy(i El b. Certified Safety Professional(CSP) <br /> CITY n. <br /> ❑ a Certified Marine Chemist(CMC) <br /> C_;;ea, ❑ d. Registered Environmental Health Specialist(REHS). j <br /> 759. <br /> PHONE--7 ` ❑ e. Professional Engineer(PE) <br /> / ()� ��` I L ❑ f. Class II Registered Environmental Assessor <br /> DATE <br /> 711, CERTIFICATION TIME ® S. Contractors'State License Board licensed contractor(with hazardous I <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763, <br /> il'yes,the sank inmdor 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: 7w. <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 and/or operator of the tank system;and the tank removal contractor. <br /> UPCF H\}'F1249(1/99)-1/2 wwutunidocs.org Rev.02/16/00 <br />