Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> __ - __-- ---- <br /> Pave of <br /> I. FACILITY IDENTIFICATI ON <br /> BUSINESS N A 1IE(Same w FACILrrV NAME or DBA-Doing Business As) 3 FACILITY 6 1 <br /> Stockton Diesel <br /> 740 <br /> TANK OWNER NAME <br /> Sherrie Balcioni <br /> 741 <br /> TANK OWNER ADDRESS <br /> 2973 Loomis Road <br /> TANK OWNER CITY Stockton 742 STATE CA 7a3 ZIP CODE 95205 744 <br /> H. TANK CLOSURE INFORMA rION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional wires <br /> of this page for more than To Center Bottom Top Center Bottom <br /> TANK the t p <br /> INTERIOR I Tank) S _ 746a 746b 7 s�y 747a 'CT747b f�r 7a7c <br /> ATMOSPHERE _l _1 <br /> READINGS 2 48 749a 749b 74 750. 7506 750c <br /> 3 751 752a 752b 752 753a 753b 753c <br /> III. CERTIFICATION <br /> On examination of the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky res dual 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 C IER STATUS OR AF ILIATION OF CERTIFYING PERSON <br /> Certifier is a repr sentative o;;��CUP authorized agency,or LIA: 7� <br /> NAME OF CERTIFIER (Pm) 754 Yes <br /> Tim Cook Name of CUPA,E uthorized agency,or LIA: 761 <br /> 755 <br /> TITLE OF CERTIFIER <br /> Professional Engineer Ifcertifrer is othei than CUPA/LIA check appropriate box below: 762 <br /> ADDRESS 756 El a. Certified It dustrial Hygienist(CIH) <br /> 1485 Treat Blvd., Ste 203A ❑ b. Certified S Lfery Professional(CSP) <br /> CITY 757 ❑ c. Certified arise Chemist(CMC) <br /> Walnut Creek ❑ d. Registered EnvironmentalHealth Specialist(REHS) <br /> PHONE 756 ® e. Profession I Engineer(PE) <br /> 925-478-8390 ❑ f Class 11 Rei istered Environmental Assessor <br /> 759 ❑ g. Contractor'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance ro moval certification) <br /> 10/27/2016 0 Z2 <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> (If yes,the tank interior atmosphere shall be rechecked with a combustible gas indicator prior m work being conducted on the tank) ® Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACIL ITY,ETC: 764 <br /> Tank has been triple rinsed and can be transported and recycle . <br /> A copy of this certificate shall accompany the tank to the recycling�disposal facility and be provided to the CUPA. Ift=cis no CUPA,copies shall be submittal to the LIA and authorized <br /> owner/operator of the tanks stem'removal contractor and the rr cvclin /disposal facility. <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />