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• s <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE JAN 2 4 2017 <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> HEALTH <br /> DEPART ENT of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Since,FACILITY NAME oroBA-coins Business As) 3 FACILITY IDN I' <br /> Carpenter Co <br /> ]40. <br /> TANK OWNER NAME <br /> Carpenter Co <br /> ]41. <br /> TANK OWNER ADDRESS <br /> 17100 South Harlan Road <br /> 141. <br /> TANK OWNER CITY Lathrop STATE CA 743. ZIP CODE 95330 744. <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies I I - - <br /> ofthispagefor mom than Top Center Bottom Top Center Bottom <br /> TANK three tanks) <br /> INTERIOR ]46. ]46a. ]46b ]46c. ]4]a. ]4]b. 741c. <br /> ATMOSPHERE 1 !(Srarr� ZU.S' z�_� <br /> READINGS 2 7 8i 749a. ]496. ]49e. � Y ]so.. Z� V ]sob. <br /> [ �-7rt <br /> /' � ]51. ]52a. 82b ]52c. ]6]a. ]Slb. ]63c. <br /> 3 le7r'L/el _q QJ� .& 00. r <br /> III. CERTIFICATION <br /> _ ._". <br /> On examination of the tank,-!certify the tank is visually Tree from product sludge,scale(thin;flaky residual of tank contents);irtiseate iidd'debit"s::I"fiidFe�"cerfify"ihaf <br /> the informatioRprovided bflCein.is true and acct(ratetp the best of,my knowledge. <br /> y-STATUSOR-AFFILIATION OF--CER�IFF-y-1F -P9RSOI11 --- <br /> ". _SIONAT PFFISR----- .-_ _—_ _____ _ . -.— <br /> 60.Certifier isa representative of[he CUPA;-authorized agency,or LlA:r+4 ❑ YesNAMEOFC -. . <br /> - . . -. ."_ . . _. Bbl. <br /> dV Name of CUPA,authorized agency,or LIA: <br /> ]ss. N/A <br /> TITLE OF ERTIFIEA <br /> 62. <br /> If certifier is other than CUPA/LIA check appropriate box below: <br /> ADDRESS ! El a. Certified Industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CSP) <br /> 757 <br /> CITY ❑ c. Certified Marine Chemist(CMC) <br /> I <br /> �•L�b -_ El d. Registered Environmental Health Specialist(REHS)IA- <br /> PHONE 7,8E] <br /> . e. Professional Engineer(PE) <br /> 7v 7 (�// /Q/ I ❑ f Class 11 Registered Environmental Assessor <br /> DATE l Db]59 bCERLTIFICATION TIME ® g Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> ]63. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (byes,the tank intenornstio hera shall be rt-checked with a combustible gas indicator pnor to.wrk being conducted 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 io the recycling/disposal facility and be provided to the agency overseeing tank closure ti.e.CUPA or other authorized local aeencv). the '. <br /> owner ankor operator ofthetankmstern and the tank removal contractor. <br /> ,,.�, rrI. .oaovunirinrc oro Rev.02/16/00 <br />