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UMFI ED PROGRAM CONSOLIDATED FORM JAN 2 4 ZOI7 <br /> HAZARDOUS WASTE <br /> -i ZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> ENVIRONMENTAL HEALTH_ <br /> DEPART Page I of <br /> 1. FACILITY IDENTIFICATION <br /> BUSINESS NAME(same as FACILITY N4 E or DBA-Brine Business As) FACILITY ID# <br /> Carpenter Co <br /> TANK OWNER NAME 14°. <br /> Carpenter Co <br /> TANK OWNER ADDRESS 741. <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop 7@. STATE CA 743. ZIP CODE 9530E7441 <br /> IL TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> onnia page for tanks) Top To Center Bottom To Center Bottom <br /> TALAR three tanks) P P <br /> INTERIOR 745. t7 146a D 7466. ,, p 746c. O 747a. 0 747b, O 747c. <br /> ATMOSPHERE I O O �/b tJ/ 16 U. 17 6 <br /> READINGS2 L.FT ;��_� oO 749a. G ]496. �� 749c. 750.. 7501, Z'0' O 750c. <br /> e 04 <br /> 3 —7 N '/J� 0 0!6 752, 0/6 7521, b 752c. 4 753a. 7536. �.� p6 755c. <br /> III. CERTIFICATION <br /> - —-- ---- <br /> On examination of the tank,1 certify the tank a vtstiallylrze Born product,sludge,scele?tYun,tla -residuaTof tahk contents7,nnseate andael- ufi—flat er cerTif`y tTiat --- <br /> _ <br /> thei information.provided herein is true and accurate to.the best of my knowledge, <br /> -=- -SIGNATU1-OFCERTIFIER-._:_- -._. ._c._:_ ._ - T,4TUS-0R=AFFILIA IC)N-O.F-CERT=l-INGPERSON -- - --- <br /> {ut I Certifier is a mpresentativeof the COPA-authorized agency,or LIA: 760. <br /> NAME OF CER IER (Print) 154' ❑ Yes ® No <br /> f <br /> D to-f �. �q v ti �+^�-�— Name of CUPA,authorized agency,or LIA: 61. <br /> TITLE OF CE IFIER n / 755. N/A <br /> f-4 e(J1f certifier is other than CUPA/LIA check appropriate box below: 761 <br /> . <br /> ADDRESS 756 <br /> �f ❑ a. Certified Industrial Hygienist(CIH) <br /> ❑ It. Certified Safety Professional(CSP) <br /> CITY 757 ❑ c. Certified Marine Chemist(CMC) <br /> L tti ❑ it. Registered Environmental Health Specialist(RENS) <br /> PHONE JJ 55 '� Ele. Professional Engineer(PE) <br /> `J cr7 q f!//W b d ❑ f. Class]I Registered Environmental Assessor <br /> DATE 759 CERTIFICATION TIME ® g. Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (try=.thetank interior atmosphere shall be rt-Necked with a combustibleeas indicator prior to work beineconductedonthetankj ❑ Yes ® No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER.DISPOSAL FACILITY,ETC: 764. <br /> A copy of this cenificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing lank closm'e(i.e.CUPA or other atahorized local adencv): the <br /> owner and/or operator of the tank system:and the tank removal contractor. <br /> UPCF HV'F1249(1/99)- 1/2 as ear.unidocs.org Rev.02/16/00 <br />