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11/07/00 TUE 09:15 FAS 209 Jag 1007 FORWARD INC. Q002 <br /> UNIVWD4ROQRfaM Cf5mmmAWn Y91II11 <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTMCATION <br /> r <br /> L FACLT,L'LY IDENTMCA'IION <br /> BILUNESS NAME(Same v FACILrr'Y t S.DBA-D-ina 9alne4t A41 s FACILITY IDtl ¢ 3 0 0 0 t <br /> MAS0K) Q;k) ` 1. C. <br /> TANK OWNER NAME r4r <br /> TANK OWNER ADDRESS 741 <br /> Pro BogVU 995;1 <br /> T1,111COWN20107Y 712 STATEeft 743 ZIP 006E 9 r5� 741 <br /> f. FZ CLOSORELYFORMATYON <br /> Tank ID g Concentration of Plauumble Vapor Concentration of Oxygen <br /> Hardt ad"limrr rani,, <br /> o kr marc than Top Center Bottom Top Center Bottom <br /> INTERIORTANK w�u(xnNal ��rr-.a��(n��//. {'�O� /y/, <br /> AlMDSPFIERH L J 4 745 vCD 746 (./ /a. 740 T6 '146- 74'h 14Y fRe <br /> r 1/ D R <br /> READINGS Z G� 746 1 74% 749h <br /> 9 'J ]!1 752a 75311 l! <br /> `v MR,/ 752- Q( t[J5 1590 tJ //q(f a 751, <br /> o D c o ` Oar <br /> III. CERTIFICATION <br /> On examination of the tank.I terrify the tank is visually free from product.sludge,state(thin,flaky residual of tank contents),rinseate and debris. I further certify <br /> that the information pm•ided herein is true and accurato m the best of my knowledge. <br /> SIGNATURE O�RTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> - M r CeMrw is a&Amsengtiys of the CIiPA,aulbrairrd agonpy,or LIA: Iso <br /> NAME OF CER W 154 0 Yes ® 160 <br /> Name of CUPA,authorized agency,or LIA: 761 <br /> TITLE OF CERTIFIER 755 N/A <br /> If certifier is other than CUPA/LIA cheek appropriate box below: 162 <br /> ALA?'RMS 756 ❑ �. Certified hafustrhl Hygienist(CIM <br /> 11 1 4 Id, (:} b. CtTiA eAA Safety P+eAessiooa5(CBP) <br /> CITY ash Q c. Certified Marine Chemist(CHIC) <br /> Dj)rAJ ❑ d. Registered Eovironmental Health Specialist(REBS) <br /> PHONE 73, §Z e. Professional Engineer(PE) <br /> IK3-2?0p L: f. Class JJ Registered Aa xsar <br /> BATE 1» CERTIFICATION TIME 0 %. Coru,r.+e:s' Sate.Iirrtme Pa 1licertced mim =(with hazardous <br /> substance removal certification) ` <br /> Met <br /> TANK PREWOUSLY ASLD FLAARMIBLE OR COAWZ147MLE MA T.51YL9LS 1 <br /> 41ryp.1h.=ktmniva,.,aph I"I ei tashackcdw7W a m b..ete aa.'u ,cuorlMor wvdabe'm,m�eemc-mil Ye] tJ NO <br /> CERTIFI R'S TANK_ 'M� L A-NA`GEIMENT INnItUC IONS MR SCRAP OEALER,MrSPOSAL FACV ITY,STC- <br /> C�IIJsk �� spelw of As fit01r- W A-f �Dit� Wits(2 Cu ySS <br /> On 11 /02/00 Forward Landfill received tw1 (615 tons) of <br /> Fiberglass debris from W.A. Crai Sn <br /> A copy of this mdgeal,W accompany Ne tank to Bre recycling/dispeal facihhy and Be provided to due C ere is no CUPA,Bovies shall h submirt l to t e UA and <br /> UPU(Il99) 201 Formerly DTSC 1249(6/98) <br />