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APPENDIX C <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />Page 1 of 1 <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (same as FACILITY NAME or DBA— Doing Business As) 3. 1 FACILITY ID # I I I I I I I I I I I 1• <br />DPIF2 CA 18 Army Court LLC 1624 Army Court Stockton CA 95206 <br />TANK OWNER NAME 740. <br />DPIF2 CA 18 Army Court LLC <br />TANK OWNER ADDRESS 741' <br />5500 Equity Avenue <br />TANK OWNER CITY Reno 742' STATE CA 743' ZIP CODE 89502 74 <br />II. TANK CLOSURE INFORMATION <br />Tank lD # 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 />three tanks) P P <br />TANK_ <br />I <br />745. 746a 746b. 746c. 4 450 a.`?4INTERIOR <br />CATMOSPHERE <br />2 <br />748. 749a. 749b. 749a a. Ob. 750b. <br />READINGS <br />3 <br />751. 752c. 753a. 753b. <br />4 <br />75 754a. 754b. 754c. Sa. 755b. 755b. <br />III. CERTIFICATION <br />f <br />tthe tank is visually free from product, sludge, scale (thin, flaky residual of tank contents), rinsate and debris. I further certify <br />On et ' ti of e I�ere�*!is <br />that t i o aio provi d true and accurate to the best of my knowledge. <br />SIGyjMCERT1hEq <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />/ <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 760' <br />❑ Yes X No <br />OF CERTAINJ( 754. <br />,NAME <br />/`� , I <br />T VF <br />Name of CUPA, authorized agency, or LIA: 761. <br />N/A <br />TITLE OF CERTIFIER 755. <br />Certified Marine Chemist <br />If certifier is other than CUPA/LIA check appropriate box below: 762• <br />❑ a. Certified Industrial Hygienist (CIH) <br />ADDRESS 756. <br />P.O. BOX 2562 <br />❑ b. Certified Safety Professional (CSP) <br />[K c. Certified Marine Chemist (CMC) <br />CITY 757. <br />Alameda, CA 94501 <br />❑ d. Registered Environmental Health Specialist (RENS) <br />O e. Professional Engineer (PE) <br />PHONE 758. <br />337-230-6695 <br />❑ f. Class II Registered Environmental Assessor <br />❑ g. Contractors' State License Board licensed contractor (with <br />DATE 759. <br />CERTIFICATION TIME <br />r <br />hazardous substance removal certification.) <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br />(If yes, the tank interior atmosphere shall be re -checked with a combustible gas indicator prior to work being completed on the tank.) X Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC. 764. <br />Schnitzer Steel <br />1101 Embarcadero West TANKS/PIPING MEETS TITLE 22 REQUIREMENTS <br />Oakland, CA 94607 CRUSH WITH HEAVY EQUIPMENT <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 <br />authorized local agency); the owner and/or operator of the tank system; and the tank removal contractor. <br />