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OCT-20-2003 16:54 RCEKER, INC. 1 559 268 3366 P.02iO4 <br /> UMFIFD PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSUU.CEI417FICATION <br /> Pane of <br /> BUSINESS NAMB(SaregFAcv=KAs1EwABA-2b:e1W�.a:) 7. <br /> i"2 <br /> f TANKOWNER NAME 1sa <br /> TANK OWNER ADDRESS <br /> 744, <br /> TANxovvNERCm' STATG,.L..,.._. . 1a5. zsconE �'3'.... . <br /> ;)II,,�'gN�S;CLOS��XNFpRMATION ` - <br /> Tank ID 0 Concentrudw of Ftammabld Vapor Gtncenhati0n of Oxygen <br /> i (AttadteseaienoltoDMs <br /> aradsphwunks) Top Center AO[lom Top Centra Bottom <br /> CNTEWuJ <br /> I OR t .ls. ease. 74on wee � 1010 7•'+P 1 u. <br /> A7MOSIe111RE <br /> riE!ANOSe. us lc7r. �-oc lsa. »a <br /> 1 2 <br /> 151. 79a 7M 132.. <br /> 3 <br /> ".IIL .CF11T FTCATION ? <br /> l On azmination of the tank,I certify the lank is v(svally free from product,sludge.scale(thin,flaky residuxl of tank conteau);rinu.Yte and debris. I further certify that <br /> the rA.ot d,,projded herein is mleand aecuraleto the best of olknowled <br /> SIONAWRE OF CSRTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> l0. <br /> CavTU <br /> t[Ga is a tesensative oY1h0 COPA,au:horizod agency,a LV+: <br /> NAME OF CERTIFIER (»m.) 7 Cl Yes r@ No <br /> authorised agme vci. <br /> Name OC CUPA, Y,or LLA; <br /> TITLE OF CBRTIFMR153N/A <br /> . <br /> ... ....__. Ice. <br /> If certifier is other than CUPA I LIA eheckappropriats box below: <br /> ADDRESS 7% r❑ya. Certited lndushia(Hygienist(CIR) <br /> LI II, Ceni fled Safety professional(CSP) <br /> CITY 757' ❑ c. Certified Marine Chemist(CMC) <br /> L1 d, Registered Env4semmmoil He01th Specialist(RE)15) <br /> PHONE Q ;, ProfossionalEngineer(PE) <br /> ❑ f. Class 11 Registered Envitoomerntal Assessor <br /> DATE y a CEATIF(CAT(ON TOME Q g• Contwors'State Lic stse Board licensed contractorus <br /> (with hazardo <br /> substance removal eMifiration) <br /> b <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> i"1. la,uuc iroibrampnarsa/sp 6a ee<hedniviharmh•NibNael(dialwfriorw oak Ori.Y eaiduesrd vx drwe.7 ❑ Yea ❑ No <br /> c— ANArWENT LNSTRU IOMMSURAP DEALER,DISPOSAL FACILITY,ETC' 761 <br /> A tippy of Nie eerHflaM shalt aceetmany the tank m the latyalirl[/diryefal&Miry and Sa pmvided no the agexy ovcnmina uak elesun(f.e.CUPA tm WMraWhorGad Taal agency); d,r <br /> awnrr r.8�a vawagrer]A•aNc ryloreq oad ew mak�mvw2 a�nweter. <br /> UPCF7f1YF120(1199)-112 bttp;1Amw.anid*w.crg Ray.021100 <br />