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i <br /> I <br /> � I <br /> I� <br /> I� <br /> TANK CLOSURE CERTIFICATION FORM <br /> MY I� <br /> BUSINESS NAM- I} 3FAclury low t <br /> $ITE ADDRESS <br /> • 1 r <br /> Bust"ESs CITY Il 105 3U&NESS ZIP <br />! 706 <br /> IVTANK CWNER NAME - <br /> s <br /> C °° <br /> TANK ER A.00RES.S ,j 501 <br /> TANK OWNER CIN ; <br /> _ 502 STATE 503 LIP 50a <br /> 11 TANW .1 QQ f <br /> I Tank 9, Flammable Vapor .J� Oxygen <br /> (State Tank IC*, if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings Il <br /> .i <br /> ir <br /> If. <br /> III CERTIEIC8110N <br /> a <br /> On examination of the tank.1 certify the tank is visually free from product.sludge,scale(thin,flaky residual of tank contents),rinseate and debris_ I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. 1� <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sas <br /> CERTIFIER NAME(PRINT) soe Certifier is a representative of the CUPA/t_iA: YES ❑ NO ❑ <br /> CERTIFIER TITLE 5o7 <br /> Name of CUPAILIA <br /> CDORE55 If certifier is otherithan CUMLIA check appropriate box below: <br /> PHONE ITY ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED 509 CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> I <br /> ❑ Certified Marine Chemist(CMC) <br /> i ❑ Registered Environmental Health Specialist(REHS) <br /> I} <br /> ❑ Professional Engineer(PE) <br /> N <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑ Yes © No This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. '1T1 <br /> it <br /> Certifiers tank management instructions for scrap dealer.disposal facility,etc: <br /> 1 <br /> A copy of this certificate shalt accompany the tank to the recyci ngldisposat facility. <br />