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' <br /> TANK CLOSURE CERTIFICATION FORM <br /> RNF � Y <br /> F <br /> auSINEss NAME /f ) 3 RACklTY iO• , <br /> SRE +JDRESa <br /> +o. <br /> eusiNEss urY i ,m auswEssa � � ,a <br /> TANK awNER NAME M <br /> TANK CwNER ADDRESS <br /> TANk O NER CITY <br /> 11 TAI OSI IRF INFQRMADQm <br /> Tank S Flammable Vacof Oxygen <br /> (Slate Tank ICS.if applksible) Tap Center Bodom Top Center Bodo <br /> Tank Interior <br /> //�� t <br /> Atmosphere �— 37� 6'�J/ <br /> Readings O <br /> III cF--q-nFfr.A-nnN <br /> j <br /> On examination of the tank.I certify the tank is visual%free from product.sludge.scale(Nin,flaky residual of tank contents),dnseate and aeons. I further certify <br /> that the information provided heroin is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON 10 i <br /> CERTIFIER NAME(PRINT) sen Certifier is a representative of the CUPA/UA: YES ❑ IVO ❑ <br /> CERTIFIER TITLE soT <br /> Name of CUPA/LIA <br /> AOCRESS If certifier is other than CUPA UA check appropriate box tbellow: <br /> Cm <br /> PHONE ❑ CertifiedIrnfustnal Hygienist(C1H) <br /> DATE CERTIFIED sa CERTIFiCATICN 7ME ❑ Cartfiea Safety Professional(CSP) <br /> ❑ Carolled Manne Chemist(CMC) <br /> ❑ Registered Ernrironmemal Health Specalist(RE=:S) <br /> P-❑❑ Professional Engineer(P-- <br /> 0 <br /> Cass 11 Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with heZardpus substane,cortrfiChe) <br /> ❑ Yes ❑ No This tank previously held flammable or combustible matenals. If yes.the tank interior abnasphem shad be reclecked wed a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifiefs tank management instructions for strap dealer,disposal facility,etc: <br /> A copy of this certificate snail accompany the tank:o the recyctingfdisoosal facility. <br />