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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE JAN 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> DEPART ENT .i <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITI'NWE or DBA-Coirm Business As) FACILITYID# l <br /> Carpenter Co <br /> 40. <br /> TANK OWNERNAME <br /> Carpenter Co <br /> TANK OWNER ADDRESS 741, <br /> 17100 South Harlan Road <br /> TANKOWNERCITY Lathrop 942_ STATE CA ]4a ZIP CODE 95330 744. <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Auaoh addi,ional copies <br /> - . . .. <br /> Of this page for n,nre than To Center Bottom To Center Bottom <br /> TANK three tanks) P P <br /> INTERI0R1 ]45. ]46a. ]466. 746c ]4Ja. ]4]b. ]a]c. <br /> ATMOSPHERE — �y` Ot 'J 2 <br /> READINGS 2 I._1_ 748. 749a. 7496. 749c. ^O '750e. _�,S]506. 750c. <br /> 3 I 751. 752. 1 7526. 752e. ^ „ s3. �. 7531, 753e. <br /> III. CERTIFICATION �( <br /> — _ . .. mfythe_.. <br /> On examination of the tank,I cztank is visually free fir tini.prodlici,sludge,scale(tfiiii;flaky'residuiil dflahk'cohii:ii[s);Fmsesfe ariA'debiSs. ITurtfier"deBiFytliaf" - <br /> _. .the informatlbn provided bereiq_i5..true and accurate tg the best of my knowledge. . _ . ._ , <br /> - -- ------ QST-ATUS�R-AFFILIATION OF-CER--RPKING PERSON- <br /> .SIGNAT ..:OF CERTIFIER.._ . .. . . -: �____" -___.- _ <br /> Certifier is-a representative of the CUPA,authorized agency,or LIA: _ 760. <br /> itt <br /> NAME,OF C.ERTWIER opnp f 759' ❑ Yes (3.No _ <br /> U U J (k1i 2 0 LJ7 4-0- f L Name of CUPA,authorized agency,or LIA: 761. <br /> TITLE OF dRTIFIER 755' N/A <br /> /7 762. <br /> T-its e �� h e s /,} vr� ,q e� If certifier is other than CUPA/LIA check appropriate box below: <br /> e <br /> ADDRESS :. ❑ a. Certified Industrial Hygienist(CIH) I <br /> L O �K c�-✓ +d✓t rr� ❑ b. Certified Safety Professional(CSP) <br /> CITY ❑ a Certified Marine Chemist(CMC) <br /> 40 �� ❑ d. Registered Environmental Health Specialist(REHS) <br /> 75S 1 <br /> PHONE ❑ e. Professional Engineer(PE) <br /> -70-7 c L rp Q ❑ f Class 11 Registered Environmental Assessor <br /> DATE 759 CERTIFICATION TIME I E g Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> ©� �3 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 70. <br /> (Ifyes,Outrank interior atmosphere shall be rechecked with a combustible was indiatorprior to work beim conducted on the tank.) ❑ Yes E No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER.DISPOSAL FACILITY,ETC: 764. <br /> A copy of this certi0cale shall accompany the lank to the recycling/disposal facilim and be provided to the agency overseeing lank closure lie CUPA or other authorized local agency): the <br /> owner and/or operator ofthe lank syslem;and the tank removal contractor. - <br /> UPCF HW'F'1249(1/99)- 1/2 ttvvi%unidocs.oig Rev.02/16/00 <br />