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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZAR]DOUS WASTE TANK CLOSURE CERTIFICATION <br />Page _-L—of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME (same as FACILITY NAME or DBA- Doing Business As) 1 1 FAC]LrrYID# I I I I I I I I I f 1 1, 1 <br />CHEVRON 208117 755 S. TRACY BLVD., TRACY, CA 95376 <br />—TANK OWNER NAME 740. <br />CHEVRON PRODUCTS; WASTE TRACKING DESK <br />TANK OWNER ADDRESS ?Z7 <br />P. 0. BOX 6004 <br />TANK OWNER CITY SAN RAMON 742 STATE CA 7 94583 744. <br />II. TANK CLOSURE INFO R ATION <br />PIPE <br />(Anad Tanaddk ID es coConcentration orFliumnalite Vapor. -'/v <br />pi <br />Concentration of Oxygen 0itional <br />TOP <br />Center Bottom <br />of ffis Pat For mom than <br />h tallks) Top Center Bottom <br />— <br />TANK <br />INTERIOR <br />1 <br />746s. <br />18-0142 745 7460. —e- <br />74& 74&. <br />— <br />.2z q 747m, <br />If <br />747h. <br />C? ?747t <br />ATMOSPHERE <br />2 <br />748. 149a. <br />749b. 749c. <br />7ML <br />750b. ISM. <br />READINGS <br />3 <br />751. 732c. <br />752h. 752c.1 <br />7534 <br />753b. 753b. <br />4 <br />754, 7541. <br />754b. 754c. <br />755 <br />755h. <br />III. CERTIFICATION <br />On examination of the lank, I certify the tank is visually free from product, sludge. scale (thin, flaky residual of tank cantents), rinsate and debris. I furthercertify <br />that the infamation provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />ER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />_I Zy <br />Certifier is a representative of the COPA, authorized agency. or LIA: 760, <br />0 Yes X No <br />NAME OF CERPFIER (Print) 754, <br />NANCY CARSAWAY <br />Name of CUPA, authorized agency. or LIA: 76t. <br />NIA <br />TITLE OF CERTIFIER 755. <br />—CERTIFIED INDUSTRIAL HYGIENIST <br />If certifier is other than CUPA/LIA check appropriate box below: 762. <br />1 le <br />A a. Certified Industrial Hygienist (CIH) <br />ADDRESS 756. <br />991 EAST CALIFORNIA BLVD. <br />0 b. Certified Safety Professional (CSP) <br />0 c. Certified Marine Chemist (CMC) <br />CITY 757, <br />PASADENA, CA 91106 <br />0 d. Registered Environmental Health Specialist (RENS) <br />n e. Professional Engineer (PE) <br />PHONE 558- <br />626-6767681 <br />0 f. Class 11 Registered Environmental Assessor <br />0 g. Contractors' State License Board licensed contractor (with <br />DATE <br />CERTIFICATION TIME <br />e:3 /Z J?zo l <br />-a, .5 4 3' 0 rox <br />I PAA- - <br />hazardous substance removal certification.) <br />"I <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br />(if yes, the tank interior atmosphere shall be m-checked with a combustible gas indicator prior to work being completed an the tank.) DE Yes 0 No <br />CERTIF1ER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC. 764. <br />AZUSA LAND RECLAMATION/WM TANKSIPIPING MEETS TITLE 22 REQUIREMENTS <br />1211 W. GLADSTONE STREET CRUSH WITH.HEAVY EQUIPMENT <br />AZUSA, CA 91702 <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. CUPAor other <br />authorized local agency). the owner and/or operator of the tank system; and the tank removal contractor. <br />