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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURECERTMCATION <br /> L FACILITY IDENTIFICATION <br /> BUSINESS NAME (sameasirACtLtrYNAtt7EarDBA—DotogBminesAs) 3 F+ACUTFYTD# ! t <br /> Y95 al.JEellDn� v /t Sf/� ° L t Z � 3� <br /> TANK OWNER NANtE 740 <br /> TANK OWNER ADDRESS 741 <br /> 00005"%,3 <br /> TANK OWNER CITY s G �( O 742 STATE C� 743 ZIP CODE �/ 2,^ 744 <br /> II. TANS; CLOSURE INFORMATION <br /> Tank ID # Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> TANK of thisthree tanks)for <br /> Top Center Bottom Top ' Center Bottom <br /> INTERIOR �,� )) 745 746a 7466 746c 747a i 747b 747c <br /> ATMOSPHERE I ® / " E <br /> READINGS7 748 749a 749b 749c 7503 i 7506 750c <br /> 3 751 752a 752c 753a 7536 753c <br /> III. CERTIFICATION <br /> On examination of the tank, I certify the tank is visually free from product, sludg , 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 LTA: 760 <br /> NAME OF CERTIFIER (print) 75<t ❑ Yes CS No <br /> IM �j ® eeL7� Name of CUPA, authorized agency, or LIA: 761 <br /> TITLE OF CERTIFIER fj92II Z ()aCl J 755 <br /> ® � If certifier is other than CUPA / LIA check appropriate box below: 762 <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist (CIH) <br /> 0 , Q b. Certified Safety Professional (CSP) <br /> CITY 7570 c. Certifieit Marine Chemist (CMC) <br /> L ❑ d. Registered Environmental Health Specialist (REHS) <br /> 758 <br /> PHONE ❑ e. Professional Engineer (PE) <br /> ❑ f. Class TI Registered Enviranmenta3 Assessor <br /> 759 Contractors' State License Board licensed contractor (with hazardous <br /> DATE CERTIFICATION TIME tttTTT ___ substance removal certification) <br /> TAM{ PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> (if yes, the tank interioratrnosphereshall be mcbecWvvilh a cornbushblegas indicator prior to work being conducted on the tanL) DQYes ❑ NO <br /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILTTY, ETC: 764 <br /> A copy of this certificate shalt accompany the tank to the recycling / disposal facility and be provided to the CUPA. If there is no CUPA, copies shallbe submitted to the LIA and authorized <br /> agency; owner 1 operator of the tank system, removal conaactor, and the recycling / disposal facility, <br /> UPCF (12199) 39 Formerly DTSC 1249 (6/98) <br />