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CALAVERAS COUNTY UNMED PROGRAM CONSOLIDATED FQ '41 <br /> HAZARDOUS WASTE <br /> HA U"OUS WASTE TANK CLOSURE CERTMCATION, aia <br /> Zu1[i <br /> gR }i <br /> L FACIIJTY IDENTIFICATION <br /> �BUSINESS <br /> NAME(S ma4lsYAEDE —DigRicaAl 3• F/ �M Y_IT t <br /> l� <br /> S Z ,/ <br /> S j (fL 004I Z 0 ZO <br /> _ TANK OWNER NAME 740. <br /> TANK OVVNER ADDRESS _ 74). <br /> 3D <br /> TANK OWNER CITY STATE 7aa_ zIp CODE 744, <br /> II.-TANK CLOSURE INFORMATION <br /> vAIGTankID f1 Concentration of Flammable Vapor Conoentmtion ofonygcn <br /> (Attach addtdonal copies <br /> TANK urihis ha for vtac Un Top Center Bottom Top Center Bottom <br /> INTERIOR` 1 / z 5 r• 745. 746x. p 746b. 746c. 7474. 7476. 7474 <br /> ATMOSPHEM IO 8 00 9 ! O O O <br /> READINGS 746. 744a 749b.• 744c. 7504 7506. 750c. <br /> a o/> �z5r-wZ. oZ. a CP-- O C) 0 <br /> D 19-5G 3 751. 752a 7526 O 752c 7534 2-- 7536 2— <br /> 753e <br /> o/g/t 5/-oo ® O <br /> WT <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 thelicst o3ly knowledge. 11 .& R�t tcl&4 770 <br /> SIG'NATURP,OF CERTIFJER _ STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Certifier is a representative of the CUPA,authorized agency,or LTA: Iso. <br /> NAME OF CER (Pum) nn 754. ❑ Yes No <br /> !� Name of CUPA,authorized agcacy,or LIA. 761. <br /> TITLE OF CERTIFIER ���i�!�l)67('-V 755. NIA <br /> If certifier is other than CUPA/LTA check appropriate box below: 762 <br /> 756. <br /> ADDRESS ❑ a. Certified Industrial Hygienist(CTR) <br /> po o 7 [Ib. Certified Safety Professional(CSP).3,6 <br /> CITY 757. ❑ c. Certified Marine Chemist(CMC) <br /> .-t/ 1) ( a ❑ a Registered Environmental Health Specialist(1tEHS) <br /> PHONE' 7% ❑ e. Professional Engineer(PE) <br /> © - 2 ,Cr e] ❑ f_ Class TTRegisterrdEnvironmental Assessor <br /> DATE 759. 1 <br /> CERTIFICATION TIME g• Contractors'State License Board licensed contractor(with hazardous <br /> e� substance removal certification) <br /> TAAK PRE OUSLY HELDFLAMMABLE OR COMBUSTIBLE MATERIALS 763. <br /> (ifyrs,the t=xinterior atTosphereAW1bero-amkolwilhacombasublcpsindiatorptiortowmkbeinewnductWonthet=L) ® Yes ❑ No <br /> CERTMER'S TANK MANAGEMENT TNSTRUCTTONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC: 764. <br /> %Qn9K5 XAyd?,r T21?eRj.v-Vx1) J <br /> A copy of this certificate shalt acemnpany the tank to the recyelingldisposal facility and be provided to the agency overseeing tank closure(i.e.CUPA or other authorized local agency); the <br /> owner ontt/or operator of the tank systetm and the tank tetnoval contractor. <br />