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LIVEL <br /> 119 <br /> UNIFIED PROGRAM CONSOLIDATED FORM ��VIRVNIVETAS <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION' <br /> Pae of <br /> I. FACILITY IDENTIFICATION <br /> BUS IN ESS NAME(SuanmPACIL11YNAME orW-Doig,11winawAs) 3• FACILITY IDI 1. <br /> TANK OWNER NAME 7411. <br /> ���_�'S--L L� T arc �o��✓> c�/'oF,2.�xc9��T�.l���f��r>�'_ <br /> TANK OWNER ADDRESS <br /> Z /ZCA/ C1114IIE- 51IllZ '26) <br /> TANK OWNER CITY C��vs ✓ 742' STATE C' 743" ZIP CODE 741 <br /> 11. TANK CLOSURE INFORMATION <br /> Tank ID N Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach.ddAim.1 mpic. <br /> TANK ib�r i-1:3)ettm Top Center Bottom Top Center Bottom <br /> INTERIOR 1 �J 745. 7464 7464 746c. 747a 7476. 747c <br /> HR <br /> ATMOSPHE J <br /> RrADINGS 2 748. 7474 7494 749c 75oa 75116. 75t1c. <br /> 3 731. 752a 7524 752a 753a 753b. 753c. <br /> III. 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. 1 further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is q representative of the CUPA,authorized agency,or LIA: 76[1. <br /> NAME OF CERTIFIER (Prim) 754. ® NO <br /> El Yes <br /> Name ofCUPA,authorized agency,or LIA: 761. <br /> TITLE OF CERTIFIERS /5'�U,'( f 755. N/A <br /> //Cl( �/� �' if certifier is other than CUPA/LIA check appropriate box below•. 762' <br /> ADDRESS 756 <br /> ❑ a Certified Industrial Hygienist(CIH) <br /> 3 ❑ b. Certified Safety Professional(CSI') <br /> 57 <br /> CTFY 757. ❑ c. Certified Marine Chemist(CMC) <br /> L/ / ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 7511 <br /> ❑ e. Professional Engineer(PE) <br /> a 3 /� �/ ❑� f. Class 11 Registered Environmental Assessor <br /> 759. lit Contraclors'Statc License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME ll substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTMI,r MATERIALS 7`1. <br /> (117yes,the I"inkrior ntmosphere.hall ba mchmLed with o combustible ger Wicaterprio(to work being amducted m the rank) Yes No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: xi. <br /> A copy of this renificato shall accompany(ho tank to the zrcym ug/disposal IBcibly and be provided to the agony omrseeing tank closure(i.e.CUPA or other authorized total agency); the <br /> owner and/or operator or the lank system;and the tank mmovnl contractor. <br /> UPCF tnVF1249(1/99)-112 http:/hvww.unldoes.org Rev.02/16/00 <br />