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TANK CLOSURE CERTIFICATION ECRM <br /> >x. a <br /> 3 FAM`rY 10• , <br /> BUSINESS NAPE <br /> LIBERTY FIRE DISTRICT <br /> SITE AOORESs <br /> 24124 N. BRUELLA ROAD <br /> BUSINESS dTY 105 ACAMPO ausINESS LP 95220 Am <br /> spo <br /> TANK OWNER NAME <br /> LIBERTY FIRE DISTRICT <br /> 50+ <br /> TANK dwNEa A008ES5 <br /> 24124 N. BRUELLA ROAD <br /> 501 sTATE XQ <br /> TANK OWNER CITY <br /> ACAMPO CA 95220 <br /> 11 TANK rt QSI IRE INFORMAIIQU� <br /> Tank s Flammable vapor Oxygen <br /> (Slate Tank 10;t.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rF:RTIFIrATIQN. <br /> On examination of the tank.I certify the tank is visually free from product.sludge.scale(thin.flaky residual of tank contents).dnseate and debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON spa <br /> CERTIFIER NAME(PRIM') sae Certifier is a representative of the CUPAA IA' YES ❑ NO Q <br /> CERTIFIER TITLE SOT Name of CUPAIUA <br /> ADDRESS If certifier is other than CUPA/UA checX aPPmPn.We box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> PHONE ❑ Certified Safety Professional(CSP) <br /> DATE CERTIFIED spa CERTIFICATION TIME <br /> Q Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed cpnmractor(with hazardous substance certificate) <br /> This tank Previously held flammable or combustible materials. It yes.the tank interior atmosphere shall be re-checked with a combustible gas <br /> El Yes ❑No <br /> indicator prior to work being conducted on the tank. <br /> CariBer's tank management instructions for soap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyding/disposal facility. <br />