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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pa.e Of <br /> I. FACILITY IDENTIFICATION 1. <br /> BUSINESS NAME(sate es PwCarfv xnnM>:m oeA-r»ine Ba+n,n.A+) <br /> 3. FACILITY ID# <br /> 740. <br /> TANKOWNERNAME <br /> 741. <br /> TANK OWNER ADDRESS <br /> 743. 744, <br /> 742. STATE ZIP CODE <br /> TANK OWNER CITY - <br /> II. TANK CLOS[IR_ E INFORMATION <br /> Concentration of Oxygen <br /> Tank ID# Concentration of Flammable Vapor Center Bottom <br /> mCenter <br /> tx Bottom TOP <br /> .[this Pee.for <br /> ore then Top 747a 7474 74% <br /> TANK <br /> three tanks) 746. 746b. 7 ' <br /> ]45. <br /> INTERIOR I750. 7506' ]5«. <br /> 749a <br /> ATMOSPHERE ]496. ]49c. <br /> ]48. 753c. <br /> READINGS 2 753a 753b. <br /> ]51. 752. <br /> 7526. 752c. <br /> 3 <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. 1 further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> 760. <br /> SIGNATURE OF CERTIFIER <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: <br /> 754. 0 Yes ® No <br /> ]bl. <br /> NAME OF CERTIFIER (Print) Name of CUPA,authorized agency,or LIA: <br /> 755. N/A 762. <br /> TITLE OF CERTIFIER <br /> if certifier is other than CUPA/LIA check appropriate box below: <br /> 716. a. Certified Industrial Hygienist(CIH) <br /> ADDRESS b. Certified Safety Professional(CSP) <br /> 757' ❑ c. Certified Marine Chemist(CMC) <br /> CITY ❑ d. Registered Environmental Health Specialist(RENS) <br /> 758. 0 e Professional Engineer(PE) <br /> PHONE <br /> ❑ f Class II Registered Environmental Assessor <br /> g. Contractors'State License Board licensed contractor(with hazardous <br /> 759. CERTIFICATION TIME substance removal certification) <br /> DATE <br /> 763- <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS Yes ❑ No <br /> in <br /> neied <br /> (ifya.the tank interior mrusPM1.re shill be recM1-kd withacnsnbunble Sasidicazor priorAPD binew,DISonthe 764 <br /> ETC: <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY, <br /> A copy of this certificate shall accompany the tank to the r-Ycling/dispOsal facility and M provided to the agency overseeing tank closure(.<.CUPA or other authorized local agency): the <br /> owns and/or.pastor of the tank system;and the tank retwval contactor. <br /> Rev.02/16/00 <br /> http://www.unidocs.org <br /> UPCF HWF1249(1/99)-112 <br />