Laserfiche WebLink
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 /> 740 <br /> TANK OWNER NAME <br /> Z04 3 <br /> 741 <br /> TANK OWNER DRESS <br /> TANK OWNER CITY 742 STATE 743 ZIP CODE D 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 To Center Bottom Top Center Bottom <br /> TANK three tanks) p <br /> INTERIOR 1 745 746a 746b 746c 747a 747b 747c <br /> ATMOSPHERE <br /> READINGS 2 748 749a 749b 749c 750a 750b 750c <br /> 751 752a 752b 752c 753a 753b 753c <br /> 3 <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 <br /> ❑ Yes No <br /> 761 <br /> Name of CUPA, authorized agency, or LLA: <br /> TITLE OF CERTIFIER / 14714 0�L �Z /, ® V S' 755 <br /> " <br /> dl./f/ ",,.— 762 <br /> If certifier is other than CUPA / LIA check appropriate box below: <br /> ADDRESS 756 ❑ a. Certified Industrial Hygienist (CIH) <br /> / e? 13 oxS500 <br /> E] b. Certified Safety Professional (CSP) <br /> ( <br /> CITY 757 ❑ a Certified Marine Chemist (CMC) <br /> Ze v 9 e7 � ❑ d. Registered Environmental Health Specialist (REHS) <br /> PHONE / L 758 ❑ e. Professional Engineer (PE) <br /> ❑ f. Class H Registered Environmental Assessor <br /> (57 759 ` r g. Contractors ' State License Board licensed contractor (with hazardous <br /> DATE CERTIFICATION TIME substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> (If yes, the tank interior atmosphere shall be re-checked 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 CUPA. If there is no CUPA, copies shall be submitted to the LIA and authorized <br /> agency: owner / operator of the tanks stem; removal contractor and the recycling. / disposal facility. <br /> UPCF ( 12/99) 39 Formerly DTSC 1249 (6/98) <br />