Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE JAN 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> ENVIRONMENTAL HEAL <br /> DEPA�ia e 1 DIMENif <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITYIDN I. <br /> Carpenter Co <br /> TANK OWNER NAME 140- <br /> Carpenter Co <br /> TANK OWNER ADDRESS 741. <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop 742. STATE CA 743, ZIP CODE 95330 744. <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID p Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> ormis page for more man To Center Bottom To Center Bottom <br /> TANK three tanks)INTERP P <br /> ATMOSPIOR I-ARE 1 D 145. O cy ]46e. ©� 7461, D p ]46c. 0 y]4)a. _)I pO]4]b. U C/ 747c. <br /> READINGS 745. J ]49a. O 749b. O 749c. �b 750a. Nl ]50b. 1 ` 750c. <br /> z I 0 7o �� 20.8 ° ZIP <br /> ll <br /> 3 2 t51. 0Ov ]52a. D� ]52b. D 6 752c. 'y�953a. 6o]Slb. -04 753c. <br /> 71 <br /> III. CERTIFICATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank contents),rinseate and debris. 1 further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> -- SIC3NAH'17R : F--CE -I€IER- --- - --.---._ ..__-___ STATUS OR-AFFILIATION OF-CERTIFYING PERSON <br /> - Certifier is a representative ofthe£UPA;authorized agency,or LIA. ___iso. <br /> NAME O\,F`CERT4 IER (print) 54. ❑ Yes ® No <br /> V 00 �0-S (`-O n�"«- Name of CUPA,authorized agency,or LIA 76L <br /> e . .... <br /> TITLE OF//C''ER IFIER /J 755. N/A <br /> ne'Y SGary res 11 a-,grtcf Aag-rt e.� If certifier is other than CUPA/LIA check appropriate box below: 762. <br /> ADDRESS 7s6, <br /> ❑ a. Certified Industrial Hygienist(CIH) <br /> CD �yr, rdv-t-„� ❑ b. Certified Safety Professional(CSP) <br /> CITY 51. <br /> ❑ c. Certified Marine Chemist(CMC) <br /> PM(-L/^y ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE 758' <br /> E]r7 1l / ,ta e. Professional Engineer(PE) <br /> !0� q t(o Fly I ❑ f Class 11 Registered Environmental Assessor <br /> >50. ® g. Contractors-State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (Iryes,the tank interior atmosphere shall be re-checked with a combustible gas indicator prior o work being conducted an the tank.) ❑ Yes ® No <br /> CERTIFIER-S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY..ETC: ]64. <br /> A cope of Ili is certificate shall accompaw,the tank to the recycling/disposal facility and be provided to the agency overseeing tank clostac(i.e.CUPA or other oulhotized local agency): the <br /> owner and/or operator of the lank system:and the lank removal coma actor. <br /> UPCF HAVIFI249(1/99)-IR n-ww.unidoes.org Rev.02/16/00 <br />