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Auk <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Pae of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME. (Same as FAC UTY NAME or DSA - [wing Business As) 3. FACILITY IDS( t- <br />TANK OWNER NAME 740, <br />el- e�fl:7el-le <br />TANK OWNER ADDRESS / 741. <br />TANK OWNER CITY �`;-� 742. STATE �� 743. ZIP CODE 7 fj 744. <br />II. TANK CLOSURE INFORMATION <br />Tank ID # Concentration of Flammable Vapor Concentration of oxygen <br />(Attach additional copies <br />of this page for mon; than <br />TANK thrix ranks) Top Center Bottom Top Center Bottom <br />INTERIOR 745. 746L 746b. 746c. 747x. 747b. 747c. <br />ATMOSPHERE 1 0 Q 0 G <br />READINGS 2 748. 749x. 749b. 749c. 7502. 750b. 750c. <br />3 751, 7532 752b. 752c. 753&. 753b. 753c. <br />III. CERTIFICATION <br />On examination of the tank. I certify the tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinseate and debris. I furtber certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 760' <br />NAME. OF CERTIFIER (Print) 754. EJ yes Z No <br />l' Name of CUPA, authorized agency, or LIA: 761. <br />TITLE OF CERTIFIER 755. N/A <br />C If certifier is other than CUPA / LTA check appropriate box below: 762. <br />ADDRESS 756. ❑ a. Certified Industrial Hygienist (CIH) <br />77�C/ �' ry (CSP) <br />C ❑ b. Certified Safe Professional CSP <br />CITY 751 <br />❑ C. Certified Marine Chemist (CMC) <br />❑ d. Registered Environmental health Specialist (RERS) <br />PHONE 75E.❑ e. Professional Engineer (PE) <br />1�5,1 7 ® f. Class II Registered Environmental Assessor <br />DATE 759. CERTIFICATION TIME Contractors' State Li cense Board licensed contractor (with hazardous <br />4substance removal certification) <br />4, <br />TANJ PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br />([(yes. the tank interior amwsphere shall be re -checked with a combustible gas indicator prior m work 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 rarik to the recycling/disposal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other authorized local agency): <br />the owner andlor operator of the tank system; and the tank removal contractor. <br />UPCF HWF1249 (1/99) -112 http://www.unidocs.org Rev. 02/16/00 <br />