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QED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATjAQ'N� g 2017 <br /> ENV <br /> I. FACILITY IDENTIFICATION DERARTMFNI <br /> BUSINESS NAME(S.mgas FAC1LIT)'NAt.ffioroBA-Doinz Beaman As) 3_ FACILITY ID# t. <br /> Carpenter Co <br /> TANK OWNER NAME ]q0 <br /> Carpenter Co <br /> TANK OWNER ADDRESS 741 <br /> 17100 South Harlan Road <br /> TANKOWNERCITY Lathrop 742, STATE CA ]93 ZIP CODE 95330 744, <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Anach additional copies <br /> .. . . . . . ._ .. . ... ._. _ -. .. ... <br /> or tnia h,o,,adk,) �nan Top Center Bottom Top Center Bottom <br /> TANK three tanks) <br /> INTERIOR y 795. 7466. 7466. 746e. 747.. 7476. 747e. <br /> ATMOSPHERE �( -7 Cf+ 'Y " f <br /> READINGS 746 749.. 749b. 749c. 750., 750b. 75% <br /> 8 . <br /> 3 Or� <br /> 752.: 752b, 752c. 753.. 753b. 53c. <br /> O �� <br /> III. CERTIFICATION <br /> On examination of the tank,I certi the[ankts bisuslh Trerc froriiroducC sludge,scale�fhm;RFesdbal ditahk donteri[t,niiseate adddetiri's:iTiirtlier cert Ihaf - - <br /> fY Y P C akY ) <br /> .... -. .the infRnnatl'on provided herein is true s�n�accurg[e[o the best of my knowledge. . ,. „ ,- .._ <br /> ----- -SIGNATUR7FCER-- ER -- --" "`- ------ ----- _ T-A.TUSY7R-AFFILIATION OF-CERTIF-PING-REASON- ::---`- - <br /> 60. <br /> i <br /> Certifier is-a representative of the CUPA;authorized agency,or LIA: - -- <br /> NAME OF CERTI R (Prim) .. . .. 754. ❑ Yes ® No <br /> "*bOu f flss �, K--h,�,rrt Name of CUPA,authorized agency,or LIA: 761. <br /> TITLE OF CtkTIFIER 795' N/A <br /> 1= t�� SCly1L� 'S ryy>.r�(v If certifier is other than CUPA/LIA check appropriate box below: 762_ <br /> ADDRESS 756, E] a. Certified Industrial Hygienist(CIH) <br /> Lao' ` a—,S f'-' Cy ❑ b. Certified Safety Professional(CSP) <br /> CITY 757. E] c Certified Marine Chemist(CMC) <br /> V 1-6 l ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 759 C] e. Professional Engineer(PE) <br /> -207- Y/6- 6G ❑ 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 /> / -e L <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 63 <br /> (Ifyes,Iheunk{marwatmosphereshall be rechecked with.combustible waindk.lorpri.,o.-ork bean.c.ndunedon thank.) ❑ 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 facility and be provided to the agency overseeing tank closure(i.e.CUPA or other authorized local agency): the <br /> owner and/or operator of the lank system;and the tank removal contractor. <br /> UPCF HNN'F1249(1/99)-1/2 ccwtv.unidocs.org Rev.02/16/00 <br />