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11 137 "M TTT 09 15 FAX 209 466 1067 FORI6ARD INC <br /> G't iLF�lQ'pRQ G�R:►atrl�O'l LiDhT�t1l1 FOP & <br /> HAZ IWOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTincAmoN <br /> I.. FA.CILM WENTMCATICN <br /> 1::51=NZSS NAME time as FAC1LMY NAME«DBA_D.,ry bwIneu A41 J FACILITY W9 ', 311010 t <br /> f TANX OWNER NAME � <br /> MARK A <br /> TANK OWNER ADDRESS 741 <br /> 7.41+�`aK OV4tiE'si CITY 742 ST 742 ZIP CCIDE 4? i5a <br /> r <br /> II. rANK CLOSURE jI -p0 R34 A7y<)N' <br /> *°dd Co <br /> ncentrabon of Flammable Vapor Canceatratton of Ox <br /> U�ltrafi addasse.t r�+ic► YSen <br /> TANK or th,p r Ore thrut11 Ton Center Bottom To <br /> A Center Bauam <br /> INTERIOR 747r <br /> a 3 KtU.`PH II �.,.._ r4� ! 74� z40 D�� 7�c �`� vera �f U <br /> READINGS i 7�g 7490 749b �y� 7a5� y [� 75oe ! 750a D2jaF 756c <br /> 3 731 7576y 7526 I70 L iS]e r4} —5 7571 79gp � <br /> M. CER'TMCAI'ION <br /> 0 2A <br /> 'On exammatlan of the tank I certify the tank is visually free f•om product $judge,scale(thin,flaky residual of tank contents), nnseate and debns I furdiar certify` <br /> st the unfanaatton provided hcrtht u true and ac=ato to Che best of my knowledgo <br /> GNATU! OF BRTIFIER STATUS OR AFFILIATION QF CERTII'YiNr,PERSON II <br /> ~ /wr C's*7TW its s nPp—mazy$of the CIIpA.;nldu xYcd ago=y, or LIA 76 E <br /> NAME OF CERTJlc <br /> 0-1 <br /> Name of CUPA,authorized agcnoy,a LTA 761 <br /> Tx'I'I.E OF CERTWMR 755 NIA <br /> + �E If cor brier Is other than CUPA./VA check appropTtaw[sox below 762 <br /> �!F>rr?RICCS 7S6 <br /> 02- Certified Industrial mygtenrst ICIM <br /> &IIf 0 b Com[.c8 Saaficty qielitastonal 4CW" <br /> CITY 757 <br /> '�'I"� [T C Certified Marine Chemist(CIvIi,�) <br /> dj)Qqv%j 0 d Repswrcd Environmental Health Specialist(REHS) <br /> PHONE 7sa 5Z e Profcsswaal Engineer(PE) <br /> 'wo—2727 01 Class l,1 BASWerr4.Fai-r0nmrcial Assrscctr <br /> DATE 7yt CERTIFICATION TIME "+ . Gosltcarkor5 State?u mise Beads[team ¢red mmatoc<�xtth hxwdous <br /> substance removal cerarleaaon) <br /> A� � <br /> F <br /> TANK PREM i'OUSLY FIELD FLA,*f bf aLE OR C0Ma'[FI LE NFA muuz 762 4 <br /> (Ir yp,Lhe talk miff"maasphera shsil he re-ltECkCd wkR*CambuxtNe gas updpe* r pRor rw w ft'ba3g zanaucnaa 4A RnC-Qpt'-f I <br /> Yi t, Ll TSO <br /> CERTMERS T"ANX 14 AiNAGIwIvSEN r rmsrit[xmrvs FOR SCRAP DEALER, 0IS21-''OSAL Fr4C&m' ETC <br /> Crl 11 /02/00 Forward Landfill reeez ved tWc. 1 ( 6-5 tons) o C <br /> Flberglass debris frOM W.A. Cray Sn <br /> copy of this cc 4r1ritc shag aeenmpany the tank to did recycling I dtaposat fautity and be provided so the C ere is no CUPA ropias shalt be submitted to Ude LIA and <br /> CSPCF(1199} 201 Fom-terly DTSC 1249(6/98) <br />