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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID# I 0 I g 3 516191 <br /> Thatcher Chemical <br /> TANK OWNER NAME 740. <br /> Thatcher Company of California-Stockton <br /> TANK OWNER ADDRESS <br /> 741. <br /> 1010 Industrial Drive <br /> TANK OWNER CITY Stockton 742 STATE CA 743. ZIP CODE 95206 744 <br /> II. TANK CLOSURE INFORMATION <br /> Tank 1D# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than TO Center Bottom TO Center Bottom <br /> TANK three tanks) P p <br /> INTERIOR I D 745. 746a, 746b. 746c. 747a. 747b. 747c. <br /> ATMOSPHERE <br /> READINGS 2 748. 749a. 749b. 749c. 750a. 750b. 750c. <br /> 3 751. 752a. 752b. 752c. 753a, 753b. 753c. <br /> `f III. CERTIFICATION <br /> On examination of the tank,I certify the tal�ik 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 94 apcurate to the best of my knowledge. <br /> J <br /> SIGNATURFiOF/ ERTIFIER �r; ,� STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> �� !/ Certifier is a representative of the CUPA,authorized agency,or LIA: 760. <br /> NAME OF CERTIFIER (print) <br /> (int) 11 ❑ Yes ® No <br /> James Kapin,MPH,CIH,CSP(CIH 8877 CP) Name of CUPA,authorized agency,or LIA: 761. <br /> TITLE OF CERTIFIER 755. N/A <br /> Manager Of EM Services,ACTenvir0 If certifier is other than CUPA/LIA check appropriate box below: 762. <br /> ADDRESS 756. <br /> ® a. Certified Industrial Hygienist(CIH) <br /> 2010 West Mission Avenue ❑ b. Certified Safety Professional(CSP) <br /> CITY 757 <br /> ❑ o. Certified Marine Chemist(CMC) <br /> Escondido ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 759. <br /> ❑ e. Professional Engineer(PE) <br /> 760-489-5600- ❑ f Class II Registered Environmental Assessor <br /> 759. El g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> 10/14/20 3:00 PM <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 work being conducted on the tank.) ❑ Yes ® No <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764. <br /> Tanks D was a poly tank that held held Sodium Hypochlorite <br /> Tank was cleaned and flushed and then cut into pieces,as described on attached 10/13/20 memo. Surface pH of debris was measured <br /> -all surface pH was between 5-7 <br /> Rinsate was collected and evalauted prior to disposal. See attached meno for additional information <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.unidocs.org Rev.02/16/00 <br />