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u <br />TANK CLOSURE CE.RTIFICATICN FORM <br />F <br />auaNEss NANE <br />li s �Bu n <br />77Aciur <br />lo. � <br />site +00RES5 <br />y5IT 3t SOCkIMI <br />tM <br />at)SINESS CITY <br />105 <br />BUSINESS ZIP IN <br />TANK C ER IMME <br />above-, <br />SCO <br />TANK CiMl RAOORESS <br />501 <br />TANK OWNER CITY <br />502 I <br />STATE 403 <br />I uP w <br />Tank x <br />;Slate Tank ICO. if applicable) <br />Flammable Vapor Oxygen <br />Top Center Bottom TopCanter <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III rFRTIF?rATIQN <br />On examination of the tank. I certiy, the tank is visually free from product. sludge. scale (thin. laky residual of tank contents), rmseate and deoris. I fuller 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 sos <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />Name of CUPAILIA <br />If certifier is OmUI other than CUPAILC1eUt appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Camfied Mahe Chemat (CMC) <br />❑ Registered Environmental Health Specialist (RETS) <br />❑ Professional Engineer (PE) <br />❑ Ctass II Registered Emironmental Assessor <br />❑ CSLB licensed contractor (Neth hazardous substance oimf(cate) i <br />CERTIFIER NAME (PRINT) so <br />CERTIFIER TITLE sol <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sas <br />CERTIFICATION TIME <br />• <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes. the lank interior atmosphere shall be re-mecxed with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Camfiers tank management instructions for scrap dealer, disposal facility, etc <br />A copy of this certificate shall accompany the tank to the recyciing/dispol at facility. <br />