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j/2008 17:34 1-209-368-1851 JIM THORPE OIL INC PAGE 03/03 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Page of <br /> L FACII,=ME.NTIFICATiON <br /> BUSINFSS NAME(Saes m FAC117Y NAME.,DBA-D.,Bu it Ag . 3 FACM=BD# I I I L <br /> c� /2EsT���aT <br /> SANS OWNER NAME ho, <br /> cJsFJ/yll�S CO G C /�C <br /> TANK{OWNER ADDRESS 741• <br /> TAIvAOWNERHY STATE • 7a3. I ZIP CODE rl'rZp. ]4s. <br /> II. TATV7K CLOSURE INFORMATION <br /> Tank ID p CDBCedCAd0A of Flammable Vapor ConcNor <br /> xygen <br /> (A>oeh nddldrnal w9ler <br /> odds GRe 6rc nose tion <br /> TANK. h=mks) Top I Ccnm1 Bottom I Top, Ij7n13-- <br /> M. <br /> 11NT—:R10R I 745. I /•� 746a. 0 7466. rdEc. I � ]i7� I70. I Ar.,1OSPNERE1../ C/READINGS M. 749a ]496749e730106.I3I 751. 75]a. 732h ]51< ]3330. I CERTIFICATION <br /> Oa examiraadao of Ne tank, I cerdfy dte lank u visually f:ee Fom produa, sludge, sc11e(rbin,:3aky rtsidual of atilt contens), cvris. I fn1121 the iofotmadon provided herein 4 nuc and.R=XrAtc to the best of my knowledge. <br /> SIGNATURE OF Cc"Li TIF Y STATUS OR AFM-1,�, IATION OF CM<rUrYCertifier is a represemad"of the CUBA, aucy,or LIP <br /> NAMZ.Of CERTRF (Ptlno 7� ❑ Yrs ® No <br /> ozzzS) Name of CUPA. aulborized agency, or LIA: <br /> Tnu OF CERTIFIER 733. N/A <br /> 701 <br /> c4 If certifier is other pian CGPA/LLA check apprrioriate box below: <br /> ADDRESS 736. I a. Certified faduslriai HYgiwist <br /> © b. Ce.afied Safety Professional(CSP) <br /> cry 737' [J c. Certified Marine Chemist(CMC) <br /> ©� 1..(7 • / 1- / ❑ d. Regism:e:t Env;roumeaW FIdW SpeeWist(KEPIS) <br /> PF.ONE '7 C. PtnfL5 m1 w Engineer. (PE) <br /> f. Ciazs II RE Cstered Environmrnuil A95CS,CY <br /> 759. g, Contractors S :•i cense Bond liceysrd con actor will haasdov+ <br /> DATE CERTIITCATION TL4IE �� <br /> suh6t�lce removal <br /> ccadoo) <br /> ©S' 1.0 ; 05 <br /> TAMC PREVIOUSLY'..TELE FL IXIN LE OR COMBUSTMLE MATERIALS 76i' <br /> (I(3e.CM�k'mu:dor aemlpheee)lull rye melec4cd-iN a mmeuWbl<,a1ln6kmr xfat m wh bein;andicad on Ae iu,k.l �p U No <br /> CBRPFtii..R'S TAMC MANAGEMEN"INSTR1 =IONS FOR SCRAP DEALER. DISPOSAL CILi.1T`!, ETC; <br /> Aaopy of ha cenifieam;hell ax =mly doe taro:m the,x ling/dlsvosal acility and be provided 10 the all=y ovenc_aanssr <br /> g i clos (].a-Cd PA or tither authadted local 49=Y): f. <br /> ole o�.ner ard/ar opemlor of Me tank system;and tie oak tmnoval 00tr9cmr. <br /> UPCF HWF1.'49(1/99)-1R htrp://w -unidoesorR Rev.OJ16100 .� <br />