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9 <br />11 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />P e of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME IS.. u FACILITY NAhM err MIA -Min amlnav As) 3 FACH.ITYID#TTTTTTT I <br />TANK OWNER NAME - 7+0 <br />E ZACD /,,Jc Gtni, EcL SToc,�Td„J <br />TANK OWNER ADDRESS _- i91 <br />TANK OWNER CITY �T'Ls 7°Z STATE ZIP CODE 711 <br />H. TANK CLOSURE INFORMATION <br />Tank ID # <br />(Aarh Wdik sl coOcs <br />Concentration of Flammable Vapor Concentration of Oxygen <br />YB <br />TANK <br />nllhu th. urda) aun <br />Top Center <br />Bottom Top Center <br />Bottom <br />INTERIOR <br />ATMOSPHERE <br />4 <br />745 <br />74 7466 <br />74 747. 74% <br />'Inc <br />READINGS <br />Sj <br />7" <br />749. 74% <br />749c 1504 75% <br />750c <br />G i 151 <br />75L 7nb <br />75k 753. 1536 <br />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 further certify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the COPA, authorized agency, or LIA: 760 <br />❑ Yes ANo <br />NAME OF CERTIFIER (Prov) 754 <br />-7 <br />' � / /yQ /C� �C <br />Name ofCUPA, authorized 761 <br />agency, or LIA: <br />TITLE OF CERTIFIER 755 <br />If certifier is other than CUPA/ LIA check appropriate box below: 'm <br />❑ a. Certified Industrial Hygienist (CIH) <br />ADDRESS 756 <br />Q ) <br />❑ b. Certified Safety Professional (CSP) <br />❑ o. Certified Marine Chemist (CMC) <br />CITY 757 <br />41-001 CA - <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engineer (PE) <br />PHONE 758 <br />Q C 6 5 <br />❑ f Class 11 Registered Environmental Assessor <br />GO g. Contractors' State License Board licensed contractor (with hazardous <br />DATE 159 <br />CERTIFICATION TIME <br />substance removal certification) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br />arm ft ula ineivam.wkm"I heuheckad with..bmdble gas Wim prier m auk beiq.oducad an th. udc) .9'Yes [I No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: 764 <br />A copy of thin certifscau shall .ecompany the unk to We recycling/ dispoul facility and be provided to the COPA. If Were is as COPA, copin shag be submitted to the LIA cad au0orized <br />n en owner / a mr ofthe tank system; removal cootrecmr, and therecycling / disposal fwility <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />