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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE JAN 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> DEPART NT of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(sameas FACILITYNAxfEor DBA-Doing Business As) 1. FACILITY IDN 1. <br /> Carpenter Co <br /> TANK OWNER NAME 7 <br /> 40 <br /> Carpenter Co <br /> 741. <br /> TANK OWNER ADDRESS <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop 74z. STATE CA 141. ZIP CODE 95330 749 <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID N Concentration of Flammable Vapor Concentration of Oxygen <br /> (Au,oh zdduum.l copies . <br /> ofthis page for moa than Top Center Bottom Top Center Bottom <br /> TANK rhme sinks) <br /> INTERIOR 745. <br /> O(OO Q746x. , b4 �Ia(Ip06.. <br /> �DY4]b. 7 <br /> 47 <br /> ATMOSPHERE 1 D 20. J 20 . 20• <br /> 06 <br /> 749a. paJ50c.748. aREADINGS 01a Y%J . 62 75L 752. ]Ste ]Slb753c III. CERTIFICATION <br /> -- - <br /> On examination of[he tank,l certify the link is visuallyfree frohi product,sludge,scale jthiii;tlaky7esidtial of tank'ddh[edl§);iiriseafe add`detih"s:lRher ce t " 2st-the information provided herein is.tme and accurate tg.the best pf my knowledge. <br /> -SIGNATU -CERTIFIER _ __, - TATUSOR-AFFILIATION OF-C€RT'IF-Y4NG PERSON <br /> z -Certifier is a representative of the CUPA,authorized agency,or LLA. 760' <br /> NAME OF CERTI I (pdrn) 754. ❑ Yes ® No <br /> O V 14-5 2. -e— Name of CUPA,authorized agency,or LIA: 761. <br /> &mow <br /> TITLE OF CERTIFIER 705. N/A <br /> 62. <br /> e ti SG* e-c r/hsGL. �i'Jr� �.�— If certifier is other than CUPA/LIA check appropriate box below: <br /> R6. <br /> ADDRESS I ❑ a. Certified Industrial Hygienist(CIH) <br /> �(L p 1 �y� �,.�-� ❑ b. Certified Safety Professional(CSP) <br /> CITY n. ❑ e Certified Marine Chemist(CMC) <br /> t �y ❑ d. Registered Environmental Health Specialist(RENS) I <br /> 758. <br /> PHONE ❑ e. Professional Engineer(PE) <br /> -7o-7 q l(. `G I ❑ f Class II Registered Environmental Assessor <br /> DATE 759. CERTIFICATION TIME ® g. Contractors'State License Board licensed contractor(with hazardous I <br /> substance removal certification) <br /> 10- 4— Ile 09 . 9 <br /> 6i. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (Ifyes,thettnk interior atmosphere shat)bore-checked with&combustible gas indicator prior to work being conducted on thetank.) ❑ Yes ® No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER.DISPOSAL FACILITY,ETC: 764. I <br /> i <br /> A copy o(tbis cenificale shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing lank closure(i.e.CUPA or other authorized local agenev): the <br /> owner and/or operator ofthe tank system_and the tank removal contractor. <br /> UPCF HWF1249(1/99)-1/2 ar,ve.unidocs.org Rev.02/16/00 <br />