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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATi& <br /> EN I <br /> at <br /> 1. FACILITY IDENTIFICATION <br /> BUSINESS NAME(same.,FACILrr)'N.An4E nr osA-ooiae a�tme:,�n FACILITY IDH t. <br /> Carpenter Co <br /> TANK OWNER NAME <br /> )40. <br /> Carpenter Co <br /> TANK OWNER ADDRESS 141' <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop 742 STATE CA J91, ZIP CODE 95330 744 <br /> 11. TANK CLOSURE INFORMATION <br /> Tank ID H Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> ofthis page for more than - - - - - - - -- - - <br /> TANK three tanks) Top Center Bottom TOP Center Bottom <br /> INTERIOR 745. )4b.. ]46b. )46c. p 111a 7411, )4)<. <br /> ATMOSH ERE I 2 O•C9 `2CJ `IC •4= <br /> READINGS 2 )4F. )49a. 749b ]49c. ]50a. ]SOb. 750c. <br /> - ► l. Zoe <br /> 3 ]51. 752.. )52b. )S2c. ]sle. JSIb. Sic .. <br /> I b ti Zn� 20 F's <br /> 111. 'CERTIFICATION <br /> O_ . <br /> n examination of[he tank,I certify the tank is visually free frdriipitiiiuci;sludge;scale(thin;flaky residual of tank coh[erits);imseate ariA"Aetiri"s:I further cerfify7list -- - <br /> .... .the informa400 provided.hereiq is true and accurate to the best o fray I:nowledci . . <br /> .SIGN UR€:OF-. -MR .._. _..... -. -. _ _. .. �STATUS:OR-AFFILIATION OF-�C€RTIF�ING-P€ASON __.r_:_ _.- <br /> 60. <br /> - - - Certifier is a representative of the CUPA,-authorized agency,or LIA: <br /> 4. <br /> _ NAMOE IFIER (Pnnp _ El Yes ® No <br /> Name of COPA,authorized agency,or LIA: - let. <br /> E <br /> TITLE OF dRTIFIER 1's. N/A <br /> /� . <br /> r'r e- (,� r �.,.� {S�,•� � 2'n e� If certifier is other than CUPA/LIA check appropriate box below: )62 <br /> 6 <br /> ADDRESS /J i ❑ a. Certified Industrial Hygienist(CIH) <br /> �y�+a"- i ❑ b. Certified Safety Professional(CSP) <br /> CITY )s) <br /> ❑ c. Certified Marine Chemist(CMC) <br /> _Pwd GA �-/� ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE )"`8 <br /> f ❑ e. Professional Engineer(PE) <br /> w� L6 (p Q[ ❑ 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 /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS ]6i' <br /> (Ifyes,the tank inmriornmosphiam shell be re-checked with a combustible eat indicator anor m..ork being conduaad 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 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 ofthe tank seem:and the tank removal contractor. <br /> UPCF HWFI249(1/99)- 12 vyvi%%.unidocs.m'g Rev.02/16/00 <br />