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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae or <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-DoInR Budneas As) FACILITY ID# <br /> City of Stockton <br /> ,4c <br /> TANK OWNER NAME <br /> City of Stockton Sidewalk at 800 East Main Street - adjacent to former Valley Motors <br /> 141 <br /> TANK OWNER ADDRESS <br /> 22 East Weber Avenue, Room 301 , Stockton, CA 95202 <br /> TANK OWNER CITY 742 STATE 741 ZIP CODE 744 <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammiable Vapor Concentration of Oxygen <br /> (Aaach additioeat copies <br /> of this pare for,$) than To Center Bottom To Center Bottom <br /> TANK three tanks) P p <br /> INTERIOR1 745 746a 746b 746c 747. 747b 747c <br /> ATMOSPHERE TA0520791 8 6 0 10 2 0 <br /> READINGS 748 749. 7496 749c 750. 75D6 750e <br /> 3 751 752. 752b 752e 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 residual 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 CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LIA: 760 <br /> NAME OF CERTIFIER (pit) 754 ❑ Yes ❑ No <br /> wi I I i am little Name of CUPA,authorized agency,or LIA: 761 <br /> TITLE OF CERTIFIER 155 <br /> geologist - contractor Ifcertifter is other than CUPA/LIA check appropriate box below: 762 <br /> ADDRESS 756 El a. Certified Industrial Hygienist(CIH) <br /> 837 shaw road ❑ b. Certified Safety Professional(CSP) <br /> ^57 <br /> CITY ❑ c. Certified Marine Chemist(CMC) <br /> stockton ❑ d. Registered Environmental Health Specialist(RENS) <br /> PHONE 758 e. Professional Engineer(PE) <br /> 8005119300 ❑ f. Class TI Registered Environmental Assessor <br /> DATE <br /> 759 CERTTFICATTON TIME © g. Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> 12/2/15 1 pm <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> �tnkxl�,J <br /> (Irm the tank interior atmosphere shall be rcrheckcd with a comhustihlc res indictor prior Io work hein2 ennducied on the tank.) ❑ Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764 <br /> 21 century enviro management <br /> 2095 newlands dr east <br /> fernley, nv 89406 <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the CUPA. If there is no CUPA,copies shall he submitted to the LIA and authorized <br /> a encvE owner/operator of the tanks stem•removal contractor,and the recycling/disposal facility, <br /> UPCF(12/99) 39 Formerly DTSC 1249(6/98) <br />