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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Page of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As 3 FACILITY ID# FT <br /> I" <br /> SSJE Properties Inc DBA.AC Trucking <br /> Tao. <br /> TANK OWNER NAME <br /> AL Nunes <br /> 741. <br /> TANK OWNER ADDRESS <br /> PO BOX 3 -Tank Location:405 S Vasconcellos Ave <br /> TANK OWNER CITY Manteca 742. STATE Ca 743. ZIP CODE 95336 744. <br /> U. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than Top Center Bottom Top Center Bottom <br /> TANK three tanks) <br /> INTERIOR 1 745. 746a. 746b. 746c. Z� l 747a. ��/ ,747b. �� �747c. <br /> ATMOSPHERE ( '/ <br /> READINGS 2 748. 749x. 7496. 749c. 750a. 750b. 750c. <br /> 751. 752a. 752b. 752c. 753a. 753b. 753c. <br /> 3 <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 further certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIG URE OF CER IFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> 760. <br /> -- �, Certifier is a representative of the CUPA,authorized agency,or LIA: <br /> r' <br /> ;;NAME <br /> OF CERTIFIER (Print) 754. ❑ Yes ® No <br /> 761. <br /> Name of CUPA,authorized agency,or LIA: <br /> ,TLE OF CERTIFIER 755. N/A <br /> If certifier is other than CUPA/LIA check appropriate box below: 762. <br /> ADDRESS 756. <br /> �{ ❑ a. Certified Industrial Hygienist(CIH) <br /> y ( ❑ b. Certified Safety Professional(CSP) <br /> 757. <br /> CITY S ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 758. ❑ e. Professional Engineer(PE) <br /> e <br /> V In ❑ £ Class II Registered Environmental Assessor <br /> 759. g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> 763. <br /> ANK P VIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br /> (If yes,the tank interior atmosphere shall be re-checked with a combustible gas indicator prior to work being conducted on the tank.) Yes ❑ No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL 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 closure(i.e.CUPA or other authorized local agency); the <br /> owner and/or operator of the tank system;and the tank removal contractor. <br /> UPCF HWF1249(1/99)-1/2 www.unidoes.org Rev.02/16/00 <br />