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`. <br />TANK CLOSURE CERTIFICATION FORM <br />..i <br />iFg1 � M <br />ciliry <br />1 FAGUTY IO • 1 <br />BUSINESS NAME <br />302 AWRESS - <br />l� 9 v S©L�rrc4 i4A-9-ch-1 <br />R <br />Ias aUSINESSLP 1015BUSINESS <br />G1Y �q (C1 M P <br />TANK OWNFA NAME 7-D I <br />� C.-� ( / 0/ 0 V r � c � �7 C'501 <br />TANK OYMER AD0A <br />Csj <br />3 4150 127 c <br />i <br />TANK OWNER ciW <br />wa STATE <br />CIA <br />Tank x <br />(State Tank Cat. if applicable) <br />Flammable Vapor Oxygen <br />Top <br />Center Bottom Top <br />Center <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III (-FRTIF;r.ATION <br />On examination of the tank. 1 certify the tank is visually free from product, sludge. sole <br />(thin, flaky residual of tank contends), rinse ate and debris. I further certify <br />that the informalton provided herein is true and accurate to the best of my knowledge. <br />scs <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />CERTIFIER SIGNATURE <br />Certifier is a representative of the CUPAA IA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) sae <br />Name of CUPARJA <br />If certifier is other than CUPA/UA check appropriate box below. <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Salary Professional (CSP) <br />❑ Certified Marine Chemist (CMC) <br />CERTIFIER TITLE sm <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sw CERTIFICATION TIME <br />❑ Registered Environmental Health Specialist (REFS) <br />❑ Professional Engineer (PE) <br />❑ Class 11 Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certiRole) <br />This tank previously held flammable or combustible materials. <br />If yes. the lank interior a mosphereshagbe re-creCKed with a combustible gas <br />indtotor prior to work being conducted on the tank. <br />p2iNo <br />management instructions for scrap dealer, disposal facility, etc: <br />fa — <br />A copy of this certificate shall accompany the tank to the M dmg/dlsposa <br />