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UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS' WASTE TANK CLOSURE CERTIFICATION <br />Page of <br />I. FACILITY:IDENTIFICATION <br />BUSINESS NAME (SameasFACIUTYNANTorDBA-Doing Business As) 3 <br />FACILITY ID# <br />i <br />{ <br />t <br />NIA <br />TANK OWNERNAME <br />Tao. <br />RODNEY D. GAEDE <br />TANK OWNER ADDRESS <br />74t <br />8476 E. KETTLEMEN LANE <br />TANK OWNER CITY LODI <br />STATE CA 743 <br />ZIP CODE 95240 <br />744 <br />H. TANK CLOSURE INFORMATION <br />j <br />Tank ID # iConcentration of Flammable Vapor <br />Concentration of Oxygen <br />(Attach Wirional copies <br />Top <br />Center Bottom <br />TANK TAN <br />ofthis page formmoraftit Top Center Bottom ( <br />1 <br />INTERIOR <br />ATMOSPHERE <br />t <br />745. <br />746a 7466. 746e, j <br />0 0 0 1 <br />747a <br /><5% <br />747b. <br /><5% <br /><5% <br />7 G <br />las. <br />74%. 749b, <br />I 741a i <br />75is. <br />150b. <br />7S <br />j READINGSZ <br />3 <br />I 751. <br />! 752a 752b, <br />1 <br />752c. <br />753x, <br />753. <br />753c. <br />i <br />III. CERTIFICATION. <br />r <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 <br />that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CERTIFIER <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />� <br />Certifier is a representative of the CUPA, authorized agency, or LIA: <br />760. <br />NAME OI ERTIF16R (r,Irt) 7�' <br />❑ Yes ® No <br />TERRY D. HAMILTON, CONTRACT'OR'S LIC #339108 A, B & HAZ <br />i Name ofCUPA, authorized agency, or LIA: <br />76I. <br />TITLE OF CERTIFIER 755' <br />N/A <br />If certifier is other than CUPA I LIA check appropriate box below. <br />❑ a. Certified Industrial Hygienist (C1H) <br />762. <br />GENERAL ENGINEERING & ENVIRONMENTAL CONTRACTOR <br />756. <br />ADDRESS <br />1502 WESTBROOK COURT <br />❑ b. Certified Safety Professional (CSP) <br />c. Certified Marine Chemist (CMC) <br />CITY 757.❑ <br />MODESTO, CA 95358 <br />❑ d. Registered Environmental Health SperWist (REHS) <br />e. Professional Engineer (PE) <br />PHONE 758.❑ <br />(209) 404.7700 <br />[] f. Class II Registered Environmental Assessor <br />g. Contractors' State License Board licensed contractor (with hazardous <br />751• <br />DATE I CERTIFICATION TIME <br />substance removal certification) <br />12!8/16 j 2:30 PM <br />TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />763' <br />(if yes. the iaakinterioraonasphereshall bemcheekedwith acambustiblegasindic=priortoworkbeing eondueredonftvmk) ® Yes ❑ No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: <br />764. <br />RECYCLE 350 -GALLON FORMER UST INTO PREPARED SCRAP METAL. <br />A copy of this certificate shall accompany the tank to the recyclingrdisposal facility and be provided to the agency overseeing tank closure (i.e. CUPA or other authorixd local agency); the <br />owner and/or operator of the tank system; and the tank removal contractor. <br />UPCF HWFI249 (1199) -112 www.unidocs org Rev. 02/16/00 <br />