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F- TANK CLOSURE CERTIFICATION FORM <br /> s FAGurva. <br /> \G_ F11C—t <br /> w <br /> ACCRSSS <br /> • y \ _ �' 105 iuSwl'SSr1p, tae <br /> WSIxF53Gry TCL ` '17Z.Ib <br /> V <br /> Soo <br /> � TAxR 00#41e INM! <br /> I l <br /> V, sot <br /> TANNCANFRADCRESS <br /> S@ STATE tar DP SN <br /> TARR CAhERGry <br /> 1a <br /> It <br /> Tanks Flammable Vapor Oxygen <br /> (Slate Tank 103,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III r.F:RTIFI('ATIQN <br /> On examination of the tank.I certify the tank is visually free from product.sludge,scale(thin,fiaky residual of tank contents),dnseate and debris. I further rsniy <br /> that the Information provided herein is true aM accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> CERTIFIER NAME(PRINT) sod Ceni(ler is a representative of the CUPAIUA: YES ❑ NO Q <br /> CERTIFIER TITLE sot <br /> Name of CUPAlUA <br /> ADDRESS If comfier is other pen CUPA/LIA Chert appropriate box below: <br /> CITY <br /> ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED sot CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> Q Carolled Marine Chemist(CMC) <br /> ❑ Registered EmrironrlenUl Health Specialist(REHS) <br /> ❑ Professional Eng)rvier(PE) <br /> ❑ Class 11 Registered EmironmenUl Assessor <br /> ❑ CSLB limned Contractor(with hazardous substance mrtlpcate) <br /> ❑Yes Q No This tank previously held fiammable or combustible materials. If yes,Ne tank Interior atmosphere shelf be re-checked with a combustible gas <br /> indicator pdor to work tieing conducted on the tank. <br /> Cardfiefs unit management Instructions for scrap dealer,disposal facility,etc <br /> I <br /> I, <br /> A copy of Ins Certificate shall accompany me lank to Me mcyCing)dLsposal faolity. <br />