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I � _ <br /> TANK CLOSURE CERTIFICATION FORM <br /> a.o. ar <br /> aU&NESS NAPE 3 FAGLITY W• 1 <br /> C0� <br /> gr <br /> STc A E55 <br /> ESQ K L=—�7 L e \ <br /> W&NE"City ` r` »s WSWEss nr' itis <br /> TANK Q'AT1Ea f4YE <br /> tANM ONMFA AOpRE$a y Spf <br /> r 7 � l.-. <br /> TANK OhNER CITY 502 STATE 503SOa <br /> A C I4P <br /> L � 6�2 <br /> t <br /> Tank t Flammable vapor Oxygen <br /> (State Tank IDS.if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Intenor <br /> Atmosphere <br /> Readings <br /> III rER71PIrATION <br /> On exammadon of the tank.I cemfy the tank is viswlty free from produ2 stooge.sole(thin,flaky residual of tank contends).rkueate and aeons_ I lumber certify <br /> that the Information provided herein is mu and 30CUrate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br /> CERTIFIER NAME(PRINT) sue Certifier is a represented"of the CUPA/UA: YES ❑ NO Q <br /> CERTIFIER TITLE Sm <br /> Name of CUPA/UA <br /> ADDRESS If certifier is other than CUPAILIA check appropriate box below: <br /> CITY ❑ Camfied ind triat Hygienist(CIH) <br /> PHONE <br /> Q❑ Certified Safety (CSP) <br /> DATE CERTIFIED sot CERTIFICATION TIME Certifkd Manne Chemist(CAG) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> Q Class II Registered Envuonmental Assessor <br /> Q CSLB iicerued g,froatsor(with hazardous substance certificate) <br /> ❑ Yes ❑ No This tank previousy,held flammable or combustible materials. If yes.the tank interior atmosphere snag be re-cnecKed wdh a 001TIbus90le gas <br /> indicator prior to work being wroucted on the tank. <br /> Carofier's tank managemem insw<xons for scrap dealer,disposal lanky,etc <br /> A dopy of this comficate snail accompany the tank to the recycmg/disoosal taclity. <br />