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i <br /> TANK CLOSURE CERTIFICATION FORM <br /> �e ar <br /> auSINES-S NAME 3 FAC1u TyiCa i <br /> 3f TE AcCASSS r6+ <br /> ausINE55CITY ia3 auCSur"ES521P 115 <br /> TANK CMea N"a <br /> I _ <br /> I L C I/J f, u 1 — <br /> TANK ViVNER AOCRES5 iai <br /> I <br /> TANK CANER CS1Y Sat STATE 56} Dpi <br /> Tank 2 Flammaole Vapor Oxygen <br /> (State Tank Ill,if applicable) Toa Center BattQm Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Read':ngs <br /> ill CFRjfFl(-ATIQN <br /> � 1 E <br /> On examination of the tank,t certify the tank is visually free from product.sludge,stale(thin,laky residual of tank contents},rinseate 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 <br /> CERTIFIER NAME(PRINT) sod Cardfier is a representative cf the CUPA/L)A: YES Cl NO Q V <br /> CERTIFIER TITLE sac <br /> Name of CUPAlLIA <br /> AOORESS it Certifier is other than CUPA/LIA check appropriate box.below: <br /> CITY <br /> i PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sea CEFt71FiCATION TIHiE C2 Certified Safety Professional(CSA) <br /> Q Cartified marine Chemist(Gmq <br /> ❑ Registered ETvirorimental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class it Registered ErMronmental Assessor <br /> ❑ CSLB licensed conaactor(witn hazardous substance certificate) <br /> Cl Yes Cl Na This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere she!]be re-checked with a combustible gas <br /> indicator prior to work tieing conducted an the tank. <br /> Cerigers tank management insttucdons for scrap dealer,disposal facility,etc. <br /> ) <br /> A copy of this certificate shall accompany the tank to the recycringldisposal facility. <br />