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UNIFIED PROGRAM CONSOLIDATED FORMS a <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERT LVi ICA-T qOX 4 2017 <br /> ENVIRONMENTM,HEAJTH <br /> I. FACILITY IDENTIFICATION DEPARTMENT <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Dore Business As) FACILITY IDk r <br /> Carpenter Co <br /> Tao. <br /> TANKOWNERNAME <br /> Carpenter Co <br /> 74t <br /> TANK OWNER ADDRESS <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop 7@. STATE CA ]A3- ZIP CODE 95330 J44 <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID 4 Concentration of Flammable Vapor Concentration of Oxygen <br /> (Much additional copies _ <br /> oFthis page for nusathm Top Center Bottom Top Center Bonom <br /> TANK three tanks) <br /> INTERIOR )95 746a. 7461 746.. 747.. 7471. 747, <br /> ATMOSPHERE 1 'EAC- -' <br /> READINGS 46 749a 7496. 1490. 750. 7506. 50c <br /> At, <br /> - - -- <br /> 3 151. 753. !� 7526. y 752o. ZO. X753.. 7536. 753c <br /> III. CERTIFICATION <br /> _ <br /> Onnezamna[ion of the tank,I certify the tank is visually free <br /> r cera if "- <br /> ._.. _ .the.information provided herein is true anQ accurate tq,the best of_my knowledge. <br /> - SIONAT OF TIFIER - --- - �T-ATUSIIR-AFFILIA'16N-OF-CFRT-IF-Y-ING-PERSON - - -- <br /> 760. <br /> .._... _.__ . .... -_ . ..Certifier is a representative of the CUPA,authorized agency,or LIA: <br /> NA <br /> � ]61- <br /> OFCE IFIER t rim) _. 754. . - ❑ Yes. ®. No <br /> r✓6 14Te , aa'/ 14 VA t, Name of CUPA,authorized agency,or LIA <br /> TITLE OF ERTIFIER Ts- N/A <br /> If certifier is other than CUPA/LIA check appropriate box below: 162. <br /> 756. <br /> ADDRESS t ❑ a. Certified Industrial Hygienist(CIH) <br /> (QYElb Certified Safety Professional(CSP) <br /> t 717, . .. <br /> CITY ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONES ❑ e. Professional Engineer(PE) '. <br /> 707 y/V 401 ❑ E Class 11 Registered Environmental Assessor <br /> DATE 159- CERTIFICATION TIME ® g. Contractors'State License Board licensed contractor(with hazardous I <br /> substance removal certification) <br /> 63. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (Ifyes,the tank interior atmosphere shall be re-checked with a combustible gas indicator pnorto wad beim cundunel 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 to the recycling/disposal Facilitc and be provided to the agency overseeing lank closure(i.e.CUPA or other authorized local agency): the <br /> owner and/or operator of the tank system;and the tank removal contractor. <br /> UPCF HWFI249(1/99)-112 wacw.unidocs.wg Rev.02/16/00 <br />