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UNIFIED PROGRAM CONSOLIDATED FORK[ <br /> HAZARDOUS WASTE <br /> jqAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Page !of el <br /> I. FACILITY IDENTIFICATION <br /> _ 1. <br /> BUSINESS NAME(Same as FACIUTY NANR1 or DBA—Doing BusinessAs) I FACILITY RM <br /> Grp `. 2 - �6!' (✓' 'v"' V 00 12 7 3 74(). <br /> TANK OWNER NAME _ <br /> Tat. <br /> TANK OWNER ADDRESS <br /> c `1 <br /> /f// 743. 744. <br /> 142_ STATE >� ZIP CODE <br /> j TANK OWNER CITY --- <br /> II. TANK CLOSURE INFORMA`fION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> ofthis page for mom than Top Center Bottom Top Center Bottom <br /> TANK three tanks) . <br /> INTERIOR I /ice;e 745. 746a. 0 746b. 74&': rt7 747x. 747b. •� �") 747c. <br /> ATMOSPHERE75oc. <br /> READINGS 2 t r 7a8. 7a9a 7496. 7491. a7 2 Ob. <br /> 99 / y <br /> 751. 752x. 752b. 752c,. 753a. 153c. <br /> r- � 7 b <br /> M. 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 Mither certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OA�CER [ STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a repro entative of the COPA,authorized agency,or LLA: 760. <br /> 754. <br /> NAME ORTIFIE (Prim). C] Yes 0 No <br /> Name of CUPA,authorized agency,or LIA: <br /> 761.: <br /> 7ss. A <br /> N/ <br /> TITLE OF CERTIFIER �/ �� �/�f��S 762. <br /> If certifier is other:than CUPA I LIA check appropriate box below: <br /> ADDRESS 756. El a. Certified Industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CSP) <br /> CITY 757. <br /> r ❑ e. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> 758. <br /> PHONE ❑ e. Professional Engineer(PE) <br /> I d 7 sem / f El f. Class II Registered Environmental Assessor <br /> 759. G— Ag. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (if yes,the tank interior atmosphere shall be rechecked with a combustible gas indicator prior to wodr being conducted on the tank) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPQSAL FACILITY,ETC: 764. <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility and be provided to the agency overseeing tank rlosme,(i.e.CUPA or other authorized local agency); the <br /> owner and/or operator of the tank system;and the tank removal contractor. <br /> I M,-V rnv11:11eo 11 root-I n www.unidoes.org Rev.02/16/00 <br />