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UNIFIED PROGRAM ! I1 t OR <br />HAZAR__'1 <br />HAZARDOUS-OUS WASTE <br />I. FACILI'I <br />BUSINESS NAME (same as FACILITY NAME or DBA- Doing Business As) <br />CHEVRON 208117 755 S. TRACY BLVD., T <br />TANK OWNER NAME <br />CHEVRON PRODUCTS; WASTE TRACKING DESK <br />TANK OWNER ADDRESS <br />P. 0. BOX 6004 <br />TANK OWNER cm SAN RADION <br />IL TANK CL <br />Tank ID a <br />Concentration of Fli <br />PIPE <br />(Aaadt addidoW copies <br />or this page tin more than <br />Top Cent <br />thrsc milts) <br />TANK <br />INTERIOR <br />las. <br />1 18-0142 <br />746e. <br />Z 7a1. <br />744x. <br />ATMOSPHERE <br />t READINGS <br />3 751. <br />752x. <br />759. <br />754x. <br />On examination of the tank, I certify the tank is visually free from prod, <br />that the information provided herein is true and accurate to the best of n <br />SIGNATURE OF CERTIFIER <br />it ZL GC LOct <br />NAME OF CER FIER (Print) <br />NANCY CARRAWAY <br />TITLE OF CERTIFIER <br />CERTIFIED INDUSTRIAL HYGIENIST <br />ADDRESS <br />991 EAST CALIFORNIA BLVD. <br />CITY <br />PASADENA, CA 91106 <br />PHONE <br />626-676-7681 <br />DATE 7S4• CERTIFICATION TIME <br />a317- A/.- 3:oG�►� <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE h <br />(If yes, the tank interior atmosphere shall be rechecked with it combustible gas <br />CERT(FIEWS TANK MANAGEMENT INSTRUCTIONS FOR SCR <br />AZUSA LAND RECLAMATION/WN <br />1211 W. GLADSTONE STREET <br />AZUSA CA 91702 <br />A copy of this certificate shall accompany the tank to the recycling/di <br />authorized local agency); the owner and/or operator of the tank systei <br />page _L__0f I <br />y IDENTIFICATION <br />3. FACILITY ID #� <br />3ACY, CA 95376 <br />I <br />740. <br />741. <br />7a2.74T ZIP CODE 945$3 74a. <br />STATE CA <br />)SURE INFORMATION <br />l0 Concentration of Oxygen <br />minable Vapor.! <br />r Bottom Top Center Bottom <br />746b. 746c t w ¢� 747s .'I 747h. >n' 747c. <br />749b. 744c. �L� 7 -Ma. 75M. 750b. <br />7439_ 753b. <br />754b. <br />7Mc. 755a 7556. nom. <br />,ERTIFICATION <br />ct, sludge, scale (thin, llaky residual of tank contents), rinsate and debris. I further certify <br />y knowledge. <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a representative of the CUPA, authorized agency, or LIA: 760' <br />754. ❑ Ycs ]X No <br />Name of CUPA, authorized agency, or LIA: 761. <br />7$5. NIA <br />If certifier is other than CUPA/LIA check appropriate box below: 762. <br />756:a. Certified Industrial Hygienist (CIH) <br />❑ b. Certified Safety Professional (CSP) <br />757. ❑ c. Certified Marine Chemist (CMC) <br />❑ d. Registered Environmental Hcalth Specialist (REBS) <br />151. ❑ e. Professional Engineer (PE) <br />❑ f. Class II Registered Environmental Assessor <br />O g. Contractors' State License Board licensed contractor (with <br />hazardous substance removal certification.) <br />763. <br />MATERIALS <br />adicator prior to work being completed on the taok.) <br />Yes El No <br />kP DEALER. DISPOSAL FACILITY, ETC. 164. <br />TANKSIPIPING MEETS TITLE 22 REQUIREMENTS <br />CRUSH WITH HEAVY EQUIPMENT <br />posal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other <br />I; and the tank removal contractor. _. <br />