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N*10• <br />TANK CLOSURE CERTIFICATION FORM <br />*00 <br />aOSINEse NA YEP - c <br />S' <br />FACWTY10• I <br />SITE A00RE55 <br />3 l� . G 2q�J� �I J� 2� <br />IW <br />suslNEss cr'Y "� _ <br />105 <br />auslNEEs nR q!5:3-76 1W <br />TANK CwNER NAME <br />�EP�2r�+��.)r o,• QA1- f:�b9!rre 141 <br />500 <br />rFw <br />TANK ONMER AOORESS <br />385 a-0 A -o <br />wr <br />TANK dwNER CITY <br />-rrt <br />502 <br />STATE 503 <br />CA <br />DR 504 <br />SCP <br />R 5 3IRF <br />INEORMA-00 <br />Tank i <br />(State Tank IDt. if applicable) <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Center <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III (-.F:RTIFICATION <br />On examination of the lank, I certify the tank is visually free from product sludge. scale (thin, flaky residual of tank contems), 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 comractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) sos <br />CERTIFIER TITLE wT <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED soa <br />CERTIFICATION TIME <br />[I Yes ❑ No This tank previously held flammable or combustible materials. <br />indicator prior to work being conducted on the tank. <br />If yes, the tank interior atmosphere shalt be rechecked with a combustible gas <br />Cartifiers tank management instructions for scrap dealer, disposal facility, etc: <br />