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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME <br /> R 3�^/392- <br /> SITE A0011E= <br /> iW <br /> 7Soo w BUSINESS CITY /�� ias BUSINESSD ��� 106 <br /> TANK OWNER NAME top <br /> NIlk llocLa <br /> TANK OWNER ADORES& $Ot <br /> TANK OWNER GTY 7@ ST TE tpS 4PZ? 70 B01 <br /> Tank 9 Flammable Vapor Oxygen <br /> (Slate Tank 109•if applicable) Tap Center Bottom Top Canter Bottom <br /> Tank Interior 3- 3gZ - 0Atmosphere <br /> Readings <br /> 3- 132- ` OZ <br /> III rrRTIFIrA-MON <br /> On examination of the tank.I cenity the tank is visually free from product.sludge,scale(thin,flaky residual of tank contems),rinseate and debris. I fuller Car* <br /> that the information provided herein is we and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br /> CERTIFIER NAME(PRINT) sce Canifler is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sor <br /> Name of CUPA/LIA <br /> ADDRESS If centiliter is other than CUPA/LIA check appropriate box below: <br /> CITY <br /> PHONE 13Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sat CERTIFICATION TIME ❑ 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 /> ❑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 /> Cartifiers tank management instructions for scrap dealer,disposal facility.etc: <br /> A copy of this certificate shall accompany the tank to the recyciing/dtsoosal facility. <br />