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TANK CLOSURE CERTIFICATION FORM <br /> R.a d <br /> iUs�NESS NAYE1?10 ] FAGUT'b• t <br /> 156 Aro <br /> SITE ADDRESS 1M <br /> WSINESS GTY 105 aU51N R 100 <br /> TANK WADER NAME <br /> SO <br /> J� <br /> TANK OWNER AaDftESS SOt <br /> TANK OWNER GTY SOI STATE 5a] aZR SOC <br /> CR <br /> Tank S Flammable Vapor Oxygen <br /> (State Tank IDS,if applicable) Top Center Banom Top Center Sodom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III (-.;ztRT1FlrATIQN <br /> On examination of the lank. I denify the lank is visually free from product sludge.scale(thin,flaky residual of tank contents),rinseale and aeons. I further certify <br /> that the information provided herein is we and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSCN Ste <br /> CERTIFIER NAME(PRINT) son hut, / Cartifier is a representative of the CUPA/L1A: YES ❑ NO ❑ <br /> CERTIFIER TITLE soT `7/J� <br /> 0 Name of CUPA/l.lA <br /> ADDRESS <br /> If certifier is other than CUPA/LIA cherX appropriate Dox Delon: <br /> c1TY <br /> PHONE ,,,_ / ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED scs CERTIFICATION TIME <br /> ❑ Candied Safety Professional(CSP) <br /> ❑ Certified Marva Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RFHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ <br /> Cass;11 Registered Environmental Assessor <br /> • CSLB licensed contractor(with hazardous substance certificate) <br /> Yes ❑ No This tank previousy held flammable or mmbuslible materials. If yes,the tank interior atmosphere shall be rechecked with a combustible gas <br /> irdiotor prior to work being conducted on the tank. <br /> Canifier's lank management instructions for soap dealer.disposal facility,etc <br /> A copy,of this cemBote shall accompany the tank to the rscyGingrcisposal facility. <br />