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FROM':SIM THORPE OIL FAX NO. :1 209 366 1851 12 2004 06:09PM P1 <br />�. UN= PROGRAM CONSOLIDATED FORM n �„ <br />RAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTMC•ATION . <br />L FAC XrY MENWICATION----- <br />BtISINESS NAME (Lae as FAMUTY NAME m CBA - DM deinm w . 7• FACII.ITX i�- .1Fi7i Od16 P3g�'► <br />/it% f /• '—� Post-itjFax <br />��TANK OWNER NAME Co. G+-"'"'CoDa <br />Pn N <br />TANK OWM ADDRESS Phone Lar. <br />/OD/ <br />la STATE xl' ZIP <br />TANK OWNER CffY �4/�© <br />EL TANS CLOSURE INFORMATION <br />Tads ID d <br />Cmxav <br />mcm of M mmabia Vapor <br />of DcyBm <br />1 raMM <br />er m mp tar mwe mm <br />Tap <br />Cearer Bodtm <br />Top <br />Cmxr 8omm <br />NK <br />TA, <br />grl'FAI0813 <br />'mae eNol <br />747 <br />000 -. <br />,.ems <br />pus. <br />D <br />7Cla. <br />AT'M0.4PIffRE <br />sFanR+Ds <br />z I:. ,.a <br />749a <br />Ley. I ,.Pe <br />778,. <br />7700. TSae. <br />731. <br />777a <br />7731. _ T$!a <br />31 <br />1 <br />M. MTMCAnON <br />Oo eaamlmadoa of dw =,L I Gasify be Mt is visua free from pro&= shWge, foaic (th= AAky retimW of mak wmma), rmscaw and dentis. I ft tdcr cc'* <br />Zhu me idformodon pravided hcr= is mne Wd aemaaa: m c bca of my knowiedge- <br />STATUS OR APFUATION OF CRTTBYID)G PERSON <br />MCNATURE OF xm. <br />Cerdfwr is a reprmpxz a of she CUPA. mhorMed agewY, or LIA: <br />754. ❑Yes ® No <br />R+aw 761. <br />Name of COPA. amhormd a6aYy. or L,4-- <br />IA:,ss <br />7M. <br />N/A <br />T2fIE OF CMUIFIDt ,sr. <br />C If cadf= is other dwm CUPA / LIA chadt app qz= tion blow: <br />7-% a. cai5ed t &=-i t aygientn (cid, <br />ADDRESS <br />7 7 (Go c%� r ❑ h. Certified Safaty Prp&99 29 (CM <br />7M" p c Catificd Maim, Chemiar (CMC) .. <br />d gegiytrred EmvsommWi Helm Specialise (RUM <br />(,/ <br />�' ❑ a. Frofessioml Eaginea (P>:1 <br />PHONE <br />6/ � r ❑ f. Cl=11 Repined EmviromdeMW &mumr . <br />lll=fm <br />Co.s =, Stan: Li cease Board lieemed wwacOr (wilt <br />739. <br />DATE CFATIMCATION TDYM adlsmaae removal eerd8eadod <br />L All- 114 <br />T OUSLY ZaM FLAMMaLE OR COMBUSTSLE MAT,a,e r c <br />tm,ac ale me lewrmwr�raaa a rt4aeeaae wee a ooh W n.wa bens o.riaom m raeL1 Ya ❑ No <br />F'OR SCR DEALEIL DISPOSAL FACI.IT'Y. ETC: <br />CERTI-lER'S TANK MANAGEMENT p�gzi CIONS -°3 <br />.� ....,d�..rArseml mdllry and a provided w dw aLa1Gy ovacedOj oak ,IOArm lie. COPA m odax aomua7a7 bed iqx' 7): <br />n eePS w ®m�eofa <br />Ole 0a7R aA/w Wa+la of me talc Sysaa: <br />Rev. oL16+h0 <br />upa Ewn249 (3/991- i!2 http:/Iwwr•aaidmes.orE <br />