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_ UNIFIED PROGRAM CONSOLIDATED FORM , — -- u <br /> HAZARDOUS WASTE pp�� �� 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATi(3I� <br /> of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY hl6 or DBA-ooing nosiness As) 3 1 FACILITY IDk1. <br /> Carpenter Co <br /> 740, <br /> TANK OWNER NAME <br /> Carpenter Co <br /> TANK OWNER ADDRESS 141 <br /> 17100 South Harlan Road <br /> TANKOWNERCITY Lathrop 742. STATE CA 141 ZIP CODE 95330 744. <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> ofmis page for more than Top Center Bottom Top Center Bottom <br /> TANK three teaks)) <br /> INTERIOR ! „ I 745. ]46a. 746b. 146a 749.. 14'16. ➢4)c. <br /> ATMOSPHERE I 1 U tP 0'ft' ' O'n'2 <br /> READINGS 2 1 748. 749,. 7491, 749c. �� /. 75or _ ✓1506. 2v 750e. <br /> b 7. v �fJ ` V <br /> el <br /> 3 ' ib 751. 752.. 1526. ]Rc. 20 V 753.. :}:20 <br /> 0 Vs` !D N�953c. <br /> III. CERTIFICATION rl lf J {v <br /> On examination of the tank,I certify the tank is Gisually free frorh�pioduct sludge,scale([lith,flzky}esidbal of lank con[Ishis);ifnseati:and"debns 'i rther bent "[he[ - <br /> .... .. .the information provided bereiq i$true and accurate Ip the best of_my knotrledge. , , . „ ,_ ,. _ __, ..__, ._- . . <br /> - S[GNAT OFC - FIER - --- --- ---- - - ------ ---- -�3TA.TUS-0R AFFILIATION OF-CERT--ff-YING-PERSON <br /> i <br /> Certifier is a representative of the CUPA-,-authorized agency,or LIA: <br /> 4. <br /> .. NAME OF CE I ER.(F6m) .- ..... . _. _ _. . _ ❑ .Yes . (� No . . . . <br /> 761. <br /> A-s Name of CUPA,authorized agency,or LIA:! 2� meati _ .. <br /> TITLE OF TIFIER 7s5. N/A <br /> -r—reG// If certifier is other than CUPA/LIA check appropriate box below: - 762. <br /> I� G 4.✓r/LC /�I�� � <br /> . <br /> ADDRESS 56li ❑ a. Certified Industrial Hygienist(CIH) <br /> yLQr .Fy-dv r�'4 �.,.` El b. Certified Safety Professional(CSP) <br /> m <br /> CITY ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> ` I <br /> 58. <br /> PHONE ❑ e. Professional Engineer(PE) <br /> �-� <br /> it C b !G G 1 ❑ E Class 11 Registered Environmental Assessor <br /> 7s9. ® g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> �2--7 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (Ifyes,the tank imerior atmosphere shall bare-checked with a combustible g.s indicator prior to work being conducted on the tank.) ❑ Yes ® No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER.DISPOSAL FACILITY,ETC: 761. <br /> i <br /> i <br /> A copy of this cenificale shall accompany[lie tank to the recycling/disposal facility and be provided to[lie agency overseeing lank closure(i.e.CUPA or other authorized local agency): the <br /> owner and/or operator of the tank system;and Ihe tank removal contractor. <br /> UPCF HWF1249(1/99)-1/2 wyctv.unidocs.m"g Rev.02/16/00 <br />