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07/23/2003 08:24 20946B3433 FIFTH FLOOR PAGE 18 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae of <br /> I FACILITY]IDENTIFICATION 0 <br /> BUSINESS NAME(Sm45FACrLrrYNAME wDaA-D¢aseusineom) FACILITY IDk <br /> TANK OWNER NNAME 740. <br /> 741. <br /> TANK OWNER ADDRESS <br /> TANK OWNER CITY STATE /¢- 74a, ZIP CODE <br /> Ail TANK°CL0SURE.`INF0RMAbON <br /> Tank ID Concentration of Flarrunable Vapor Conerntrotion of Oxygen <br /> (Arnehaddkimicopies <br /> 4lth"p;Be briioict z. Top Center BottomToy Ccnwr Bottom <br /> TAMC three to ) <br /> IPREFIHEit 1 745. 746474746e. 746e 747471L747 14h. <br /> ATMOSPHERE <br /> READINGS 2 748. 749. 749b, 749.. 750. 73ob. 75%. <br /> 3 J51. 757. 752& 752.. 753. ]Sl& 755e. <br /> HI. .CERTIFICATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank content0jinscate and debris. I further certify that <br /> the inrormation provided herein is true and accurate to the best of myknowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> .We- 5<q�y�uv Certifier is a representative of the COPA,authorized agency,or LEA: 70. <br /> Cc,Gir �: <br /> NAME OF CERTIFIER (Pri¢q 754. ❑ Yes ® No <br /> Name of COPA,authorized agency,or LIA: 761. <br /> TITLE OF CERTIFIER 755. N/A <br /> 76+. <br /> If certifier is other than CUFA/LLA check appropriate box below: <br /> ADDRESS 756. ❑ a. Certified industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CSP) <br /> CITY 757. ❑ e. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 7% ❑ e. Professional Engineer(PE) <br /> ❑ L Class II Registered Environmerital Assessor <br /> DATE 759. CERTIFICATION TIME ❑ & ConRactors'State License Board licensed contractor(with hazardous <br /> substance removal ter ificarion) <br /> 761. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> Ilfya,the t4nk mtcipr atR05pIMCJapll be rechecked rvihac.mWsnbtc yaf mdiemorpnorm¢'ark bring e4nduaed o¢the unF) ❑ Yes ❑ No <br /> CERTIFIEWS TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764. <br /> A copy of this certificate ahull accompany the tank to the reeyelinp/disposal fuility a�be ynvided m the agency overseeing ask closure(i.e.CUPA or other authorized local agency); the <br /> ow randlor oycramrorthe tank system and the mnkremo %center. <br /> UPCF NWF1249(1799)-12 http://aww.unidoa.org Rev.02JI6100 <br />