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06/02/2005 10:26 FAX 510 614 8°Aq PARADISO MECHANICAL Z016 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> IIAZARDOUS WASTE <br /> 14AZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> �r Page of <br /> t I,FACILITY IDENTIFICATION <br /> t. <br /> BUSINESS NAME(3nme as FACILITY NAME or DBA—,Dving Bu=ine::As) 3' FACILITY ID# <br /> SHELL- SAP Iq, I� — 17CO M.,,a,aj C) 4Ciir; S'ICCMl iq, CA �15?12. <br /> 740. <br /> TANK OWNER NAME <br /> SHELL OIL PRODUCTS US <br /> Tal. <br /> TANK OWNER ADDRESS <br /> 12700 NORTHEOROUGH DRIVE <br /> TANK OWNER CITY HOUSTON74z. STATE TX 743 ZIP CODE 77067-2502 744' <br /> II.TANK CLOSURE INFORMATION <br /> jaddiLional <br /> ConeantMlion of Flammable Vapor Concentration of Oxygen <br /> (A[Wtopics <br /> of chiore than Top Cotter Bottom Top Cooter Bottom <br /> TANK ) 7474- <br /> INTERIOR 74s_ 746a 746h. 746c- �y a:rATMOSPHERE `�749b +, 7a9c. 150a. .r, 750b. 750b. <br /> READINGS 2 7aa. 07a9e. 7520. 753a. 753b.3 "J 751. (; 752a. <br /> III.45 <br /> CERTIFICATION <br /> On examination of the tank,I certify the tank is visually free from product,Sludge,scale(thin,flaky residual of tank contdnts),tin-77 and debris_I further certl- <br /> fy that the information provided hereat is true and accurate to the best of my lmowlcdge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> a <br /> Certifier is a representative of the CUPA.authorized agency,or LTA: 760 <br /> NAME OF C TIPIER(Print) 754- [1 'Yes No <br /> 761. <br /> Name of CUPA,authorized agency,or LIA: <br /> TITLE OF <br /> 755 <br /> CERTIFIER . N/A <br /> if certifier is other than CUPA/LLA check appropriate boa below: <br /> 762 <br /> ADDRESS 756' ❑ a. Cerdfred Industrial Hygienist(CIH) <br /> O b. Catifted Safety Professional(CSP) <br /> 757. ❑ c, Certified Marine Chemist(CMC) <br /> CITY <br /> k�,r SI��1\{�L , (_: t� .((,�J E] d, Registered Environmental Health Specialist(REIMS) <br /> 758. ❑ e, Professional Engineer(PE) <br /> PHONE <br /> -ICS.`�i fir{k,7�1 ❑ f. Class II Rcgistcrcd Environmental Assessor <br /> DATE 759, CERTIFICATION TIME ❑ g. Contractors'State License Board licensed contractor(with <br /> hazardous substanec removal certification. <br /> 763. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> Yes [:1No <br /> (If yes,the tank interior aunoephere shall be rc-ch-ked with u combustible gee indicator prlor to work being complaed on the wnkJ <br /> �I <br /> 764. <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC. <br /> VL-AJ)100)IAN11"A L TANKS/I'IPING MEETS TITLE 22 REQUIREMENTS <br /> ZIJ01:1 N� VAf;JU i'luk i CRUSH WITH HEAVY EQUIPMENT <br /> ].CVE AREL, (A, 94.5)0, <br /> A copy of this certificate Sba oaccompany wner and(or hetktoo nhe recyclisnyg/ spo�a facility be <br /> provided to torthe agency overseeing tank closure(i.e.CUPA or other <br /> authorized local agency): operator <br />