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y <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION' <br /> Pae of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Stlmc u FAC(Lrry NAME or DBA—DotaQ Business As) } FACILITY IDo 1 <br /> WXR <br /> TANK O° • INCr1(f�e�' ..�� �•�7 � Ce� ,I 6 w I/ <br /> 740 <br /> c <br /> TANK OWNER[ADDRESS 74t <br /> 0-6 r <br /> TANK OWNER CITY /�_�.." lar STATE �' 74� ZIP CODE r <br /> II. TANK CLOSURE.INFORAIATION <br /> l <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Adach.ddidon.l cvptd <br /> 'rANiC _ aftf,isp oro )rethan ,l,o <br /> Center Bottom Top Center Bottom <br /> ATMOSPHERE 1 RJOR 745 746a - 746b 746e 747. 747b 747c <br /> 4 READINGS 2 746 799. 749b 74 c 750. TSeb a <br /> 3 751 753. 752b 752c TS]a 7536 <br /> T53c <br /> III, CERTIFICATIO <br /> On examination of the tank,I certify the tank fs visually free from product,sludge,scale(thin,flaky residual of tank conten(s),ririMte and debris. I further certify that <br /> the information provided h a is true and accurate to the best of my knowledge, <br /> SIGNATURE OFC T[F[ER STATUSOItAFFILIATIONOFCERTIFYING'PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or EIA: 760 <br /> OF CE TIFIER (Atnt) 75s <br /> © Yes �Na <br /> Name ofCUPA,authorized agency,or LIA: 76t <br /> TITLE OFCERTIFIER 755 <br /> If cerci tier is other then CUPA!LIA check appropriate box below_ 763 <br /> 75 <br /> r. ❑ a. Certified Industrial Hygienist(CIH) <br /> =6v <br /> oX ❑ b. Certified Safety Professional(CSP) <br />` CITY 757 4 c. Certified Marine Chemist(CMC) <br /> ❑ d. Regisicrod Environmental Health Specialist(RENS) <br /> PHONE i ]71 ❑ C. Professfonal Engineer(PE) <br /> o? S <br /> ❑ e. class n Registered g stored Environmental Assessor <br /> T59 Contractors'State License Board licensed contractor(with hazardous <br /> -SATE CE&TIFICATION.TIME 0-91 <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> (7f yes,are lank livaiw atmosphere rhal be ro-elsckod with a combwWo gu indicator prior to work being eoeducled on tho tuc)L) Yes ❑ NO <br /> CERTIFTER'S TANK MANAGEMHIYI INSTRUCTIONS FOR SCRAP DEALER,D15POSAL FACILITY,E c-. 164 <br /> copy.of Ihls certificate shall aaotnpany the tank to the recycling/disposal facility end ba provided to the CUPA. Iftheae is oo CtJPA,copies sttall'hc submined to the L[A and authorized <br /> a eoc owner!o orator of the tanks stem-removal contractor,and the rec cltn f di n]ficiG <br /> UPCF(1?J99) FormL DTs <br /> x C 124 9 6/98 <br /> i . <br />