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TANK CLOSURE CERTIFICATION FORM <br />Page _ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME 3 <br />FACILITY ID x 1 <br />SITE .ADDRESS 104 <br />BUSINESS CITY 105 <br />BUSINESS LP 106 <br />TANK OWNER NAME Soo <br />TANK OWNER ADDRESS 501 <br />TANK OWNER CITY 502 <br />STATE 503 <br />1 ZIP 504 <br />DTSC 1249 (44W:) (6198) <br />TanK Interior <br />Atmosphere <br />Readings <br />Tank # <br />(State Tank ID#, if applicable) <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Center <br />Bottom <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 <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />Name of CUPA/LIA <br />If certifier is other than CUPA/LIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) 5o6 <br />CERTIFIER TITLE 507 <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED 5o8 <br />CERTIFICATION TIME <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. <br />Certifier's tank management instructions for scrap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />DTSC 1249 (44W:) (6198) <br />