Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME (Same asFACn1TYNAMEorDIIA — Doing Business As) 34 FACILITY ID# 1 . <br /> TANK OWNER NAME 740. <br /> VIEG o0/i <br /> TANK OWNER ADDRESS 741 . <br /> RE <br /> TANK OWNER CITY ® �' G � 742. STATE 743 . ZIP COD& P5 ✓J 74a. <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID 9 Concentration of Flammable Vapor <br /> (Attach additional copies Concentration of Oxygen <br /> of this page for more than <br /> TANK three tanks) Top Center Bottom Top Center Bottom <br /> INTERIOR 745, 746x. 746b, 746c. 747a. <br /> ATMOSPHE 7476. 747a <br /> READINGS 2 748. 749x. 749b. 749c, 750a. 7506. 750c. <br /> 3 751, 752x, 752b, 752c, 7S3a. 753b. 753c, <br /> III. 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 /> SIGNATURE OF CERTIFIER STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA, authorized agency, or LLA: 760' <br /> NAME OF CERTIFIER (print) y <br /> (Pring . . ❑ Yes No <br /> od �i Ij� ?� Name of CUPA, authorized agency, or LIA: 761 . <br /> TITLE OF CERTIFIER 755• N/A <br /> Z07%) 615" 60%);4. � e iet If certifier is other than CUPA / LIA check appropriate box below-. 762' <br /> ADDRESS 756. <br /> ❑ a. Certified Industrial Hygienist (CIH) <br /> v3V ❑ b. Certified Safety Professional (CSP) <br /> CITY 757. <br /> ❑ o, Certified Marine Chemist (CMC) <br /> l <br /> 4/ ) �j / ❑ d. Registered Environmental Health Specialist (REHS) <br /> PHONE 758. <br /> ❑ e. Professional Engineer (PE) <br /> o / ❑ f. Class II Registered Environmental Assessor <br /> DATE 759• CERTIFICATION TIME g• Contractors' State License Board licensed contractor (with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 . <br /> (if yes, the tank interior atmosphere shall be re-chgcked with a combustible gas indicator prior to work being conducted on the tank) Yes ❑ No <br /> CERTIFIEWS TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPQSAL 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 />