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06/02/2005 10:27 FAX 510 614 8'06 PARADISO MECHANICAL 2018 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Page l of I <br /> I.FACILITY71DENTf'ICATION <br /> BUSINESS NAME(some xn FACILITY NAME or DGA—Doing Buainoss As) 3' FACILITY ID# t <br /> SHELL- SAP 136146 -- 7 7CO r-1M)>JL:cuV)ITXTZf, aI=V, CA +)_5212 <br /> 740. <br /> TANK OWNER NAME <br /> SHELL OIL PRODUCTS US <br /> 741. <br /> TANK OWNER ADDRESS <br /> 12700 NORTHBOROUGH DRIVE <br /> TANK OWNER CITY HOUSTON 74Z1 STAT , `" TX 743. ZIP CODE 77067-2502 744 <br /> II.TANK CLOSURE INFORMATION <br /> `a? &oat x Concentration of Flammable Vapor Concentration of Oxygen <br /> (Atlt¢cb additioayl EaplCe <br /> of dtis page for more Lb- Top Center Bouom Top Center Bottom <br /> I1�zthree tanks) <br /> INTERIOR . r ; 746a. 7 1 747, 747b. :f r; <br /> 747c. <br /> arR) t) <br /> ATMOSPHIItE REAINGS 746. 749x- <br /> 749C• 750a 750b 7506, <br /> 3 7�i, 752E 1524. 752c. 7531 753b. 753b <br /> I.H.CERTIFICATION <br /> On examination of the tank,I cenify the tank is visually free from product,sludge,scale(thin,flaky residual of tank:contents),tin?T1?and debris-I further certi- <br /> fy that the information provided herein 6 true and accurate to the best of my knowtcdee. <br /> SIGNATU$E OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> 1 Certifier is a represeumtivc of the CUPA,authorized agency,or LIA: 760- <br /> - <br /> NAME OFICERTI1'IER(Print) 754• ❑ Yes X No <br /> i t w" t ]Name of CUPA,authorized agency,of LIA: 761. <br /> TITLE OF CERTIFIER 755. N/A <br /> If certifier 6 other than CUPA/LIA check appropriate box below- 762 <br /> 1'�i9k�f1`1'11 Cd;trl`ii.51' . <br /> ADDRESS 756. ❑ a. Certified Industrial Hyocnist(CIH) <br /> t 111 <br /> OF 20L11 ST. ❑ b. Certified Safery Professional(CSP) <br /> CITY 757. ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. RcgistcredEnvironrrtontalHealthSpccialisr(REHS) <br /> PHONE 7�9. ❑ e. Professional Engineer(PE) <br /> ylt `�3-0J75 El f Class II Rcgswred EnvironmentalASSeSSM <br /> DATE 759- CERTIFICATION TIME ❑ g- Contractors'State License Board licensed contractor(with <br /> hazardous substance removal ccrtificatioo. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (If yes,the tank interior atmosphere shall be me hacked with a combustible gas indicator pnor to work being complacd on the tank) Yes ❑ No <br /> CERTIFIER'$TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC. 764. <br /> Val t" ROAD IAl' ll.:l. TANKS/PIPING MEETS TITLE 22 REQUIREMENTS <br /> 4031 )J. VASf,Y.1 <br /> J.:J:�l�il° v CA 9/1,:5"d'1 CRUSH WITH HEAVY EQ[7TPMENT <br /> A copy of this cenificatc shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank closure(i.e.CUPA or other <br /> authorized local agency);the owner andlor operator of the tank system;and the tank removal contractor. <br />