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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 (Sante as FACILM NAME or DBA - Doing Business As) 3 FACILITY ID# 3p_ 0 31 $ 8 l <br /> Spaulding Trust Property 1 ewa area ot NorthElDora o Street <br /> 740 <br /> TANK OWNER NAME <br /> Spaulding Trust Property <br /> 741 <br /> TANK OWNER ADDRESS <br /> 1434 Third Street, Suite D , Napa , CA 94581 <br /> TANK OWNER CITY 742 STATE 743 ZIP CODE 744 <br /> II. TANK CLOSURE INFORMATION <br /> Tank ID # Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than Top Center Bottom Top Center Bottom <br /> TANK three tanks) <br /> INTERIOR I ail 745 2 746a 5 746b 5 746c O 747a 2 747b 0 747c <br /> ATMOSPHERE tt 5 8 <br /> READINGS 2 748 749a 749b 749c 750a 750b 750c <br /> 3 751 752a 752b 752c 753a 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 fin-ther certify that <br /> the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF CERTIFIER ��`"" a t "r�� STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> wn 760 <br /> 7473 ` Certifier is a representative of the CUPA, authorized agency, or LIA: <br /> NAME OF CERTIFIER (Print) �� c, 754 ❑ Yes ❑ No <br /> William Little 761 <br /> Name of CUPA, authorized agency, or LIA: <br /> TITLE OF CERTIFIER 755 <br /> Geologist - Agent 762 <br /> g g If certifier is other than CUPA / LIA check appropriate box below: <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist (CIH) <br /> 837 Shaw Road <br /> ❑ b. Certified Safety Professional (CSP) <br /> CITY 757 El c. Certified Marine Chemist (CMC) <br /> Stockton , CA 95215 <br /> ❑ d. Registered Environmental Health Specialist (REHS) <br /> PHONE 758 ❑ e. Professional Engineer (PE) <br /> 800-511 -9300 <br /> ❑ f. Class 11 Registered Environmental Assessor <br /> DATE 759 CERTIFICATION TIME IN g• Contractors' State License Board licensed contractor (with hazardous <br /> 02 /03 / 1710 : 15 am substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS Unknown Fuel possible 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 /> CERTIFIEWS TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC : 764 <br /> Disposal of UST as scrape metal . C p E <br /> JUL 2017 <br /> A copy of this certificate shall accompany die tank to die recycling / disposal facility and be provided to the CUPA. If there is no CUPA, copies shall be submitted to the LIA and authorized <br /> agency; owner / operator of the tanksystem; removal contractor,• and the recycling / disposal facility. <br /> ENVIRONl.P€ i� <br /> UPCF ( 12/99) 39 Formerly DTSC 1249 (6/98) <br />