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TANK CLOSURE CERTIFICATION FORM <br /> allWNEW NAME 3 FAGUTY'" t <br /> SITE ADDRESS 1W <br /> WSINESs CrY IoS auSINESS LR lbs <br /> TANK OWNER NAME 500 <br /> TANK ONmER ADDRESS 501 <br /> TANK OWNER CITY 501 STATE 5o3 I AR SOK <br /> I[ TANK j QStIE?EINEQ1RMA33QN_ <br /> Tank A Flammable Vapor Oxygen <br /> (State Tank IDA.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> Ill C.'PRTjFiCATIQN <br /> On examination of the tank.1 certify the tank is visually free from product.sludge.scale(thin,flaky residual of tank contemn),rinseate and debris. I fuM-wcertify <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 sas <br /> CERTIFIER NAME(PRINT) soe Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sm <br /> Name of CUPA/LIA <br /> ADDRESS If certifier is other than CUPAILIA check appropriate box below: <br /> CITY <br /> ❑ Certified Indusfnal Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED sae CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ CertAled Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REAS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑ Yes ❑No This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere stall be m-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifiers tank management instructions for soap dealer,disposal facility,etc: - <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />