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. 4 <br /> ORECF:;VED <br /> UNIFIED PROGRAM CONSOLIDATED FORM JAN 2 4 2017 <br /> HAZARDOUS WASTE <br /> ::HA:Z:A:R:D:OUS WASTE TANK CLOSURE CERTIRf/AMOMENTAL HEALT <br /> Page 1 of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(sam.a.FACILITY rvAYde DR A oo na ea Aa) PACILITY IDA ILLD <br /> Carpenter Co _ <br /> 'TANK OWNER NAME <br /> Carpenter Co <br /> vat. <br /> TANK OWNER ADDRESS <br /> 17100 South Harlan Road <br /> TANK OWNER CITY Lathrop 74" STATE CA 743. ZIP CODE 95330 744. <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID A Concentration of Flammable Vapor Concentration ofOxygetn <br /> (Attrchadafornl colic ---_ - <br /> otnhEpage for gore than I Top Center Bottom Top Center Bottom <br /> TANK three tomo) _ <br /> INTERIOR 745 ,, 746a 7466 746,, -y 747. 1171, I'M <br /> ATMOSPHERE 115 .75 -- �j t% { De'�C 2j0rev z� <br /> READINGS 2I IIfi 748 749a - T49b ) 74% 75N, 5 7501, ' 75Uc. <br /> 3j <br /> IH �752a - -._-+C6 -- Sic —r -763e. 751b 753c. <br /> III, CERTIFICATION <br /> On examination of the tank,I certify the tank Is visually free from product,sludge,scale(thin,Flaky residual oftank contents),rinseate and debris. I further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNA'*OFCIEItSTATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 760NA(v1Erint) l 754 ❑ Yes ® No <br /> O L J j q—f �+D a hS I K.� Name of CUPA,authorized agency,or LIA: 761 <br /> "TITLE OF C'LUTIFIER //7/ 755 N/A <br /> "v wa If certifier is other than CUPA/LIA check appropriate box below: 762. <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist(CIH) <br /> 4 I D ( �n f� �,g}„ ❑ b. Certified Safety Professional(CSP) <br /> CITY 757 ❑ c. Certified Marine Chemist(CMC) <br /> C t a- G ❑ <br /> it Registered Environmental Health Specialist(REHS) <br /> PHONE , / 758 ❑ e. Professional Engineer(PE) <br /> 71 7 I V {o O 7.7 ❑ f. Class 11 Registered Environmental Assessor <br /> DATE J59 CERTIFICATION TIME ® & Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMB US 1113 LE MA I ERIALS 763 <br /> (nyea,the tank;....i.r nttran here shall bele-chocked ,oh combuNiblc ons lnJlcalur Priorw work baro,cnrd.,cd-,be tank) ❑ Yes ® No <br /> __ <br /> CERTIPIER'S TANK MANAGFMHNT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FAC ILI"TY,El'C. 764 <br /> A copy of this certificate shall accompany the lank to the r.,cI,"Id iopusal facility and be provided to:he agency overseeing tank closure(i a CUPA or other authorized local agency); the <br /> caner and/or operator of the one synern:and the Wok rano so l cony actor _ <br /> UPCF IIWF1249(IN9).112 www.unidoc3.org Rev,02/16/00 <br />