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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br /> Pae of <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3• FACILITY ID# 1• <br /> TANK OWNER NAME 740. <br /> TANK OWNER ADDRESS 741. <br /> TANK OWNER CITY 742. 1 STATE 743. ZIP CODE 744. <br /> H. TANK CLOSURE INFORMATION <br /> Tank ID# Concentration of Flammable Vapor Concentration of Oxygen <br /> (Attach additional copies <br /> of this page for more than <br /> TANK three tanks) Top Center Bottom Top Center Bottom <br /> INTERIORl 745. 746x. 7466. 746c. 747. 747b. 747c. <br /> ATMOSPHERE <br /> READINGS 2 748. 749x. 749b. 749c. 750. 750b. 750c. <br /> 3 751. 752x. 752b. 752c. 753x. 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 LIA: 760. <br /> NAME OF CERTIFIER (print) 754. ❑ Yes ® No <br /> Name of CUPA,authorized agency,or LIA: 761. <br /> TITLE OF CERTIFIER 755. N/A <br /> If certifier is other than CUPA/LIA check appropriate box below: 762. <br /> ADDRESS 756. C3 a. Certified Industrial Hygienist(CIH) <br /> ❑ b. Certified Safety Professional(CSP) <br /> CITY X57- ❑ c. Certified Marine Chemist(CMC) <br /> ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 758. E:1 e. Professional Engineer(PE) <br /> ❑ f. Class II Registered Environmental Assessor <br /> 759. E:1 g. Contractors'State License Board licensed contractor(with hazardous <br /> DATE CERTIFICATION TIMEEsubstance removal certification) <br /> 763. <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <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 /> CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL 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 />