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TANK CLOSURE CERTIFICATION FORM <br />I <br />BUSINESS NAME <br />3 <br />FACIl�iY 10• I <br />SITE AOORESS <br />IG <br />BUSINESS CIN <br />IDs <br />aUSINESS LP its <br />TANK Gi NAME <br />%0 <br />TANK OWNER ADDRESS <br />AI <br />TANK OWNER CITU <br />503 <br />STATE Mol] <br />1 HP SM <br />11 TANK I fRFINFQRMAEQhL- <br />Tank A <br />(Slate Tank IDS, if applicable) <br />Flammable Vapor Oxygen <br />Too <br />Center Bottom TopCanter <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />-;-I G- `� <br />III C'I=RTIFIrA'TI0N <br />On examination of the tank, I certify the tank is visually free from product. sludge. scale (thin, flaky 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 <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 50.5 <br />Certifier is a representative of the CUPAILIA: YES ❑ NO Q <br />Name of CUPAILIA <br />If certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specsalist (RENS) <br />❑ Professional Engineer PE) <br />❑ Class 11 Registered Environmental Assessor <br />❑ CSLB licensed contractor (with he¢aroous substance certificate) <br />CERTIFIER NAME (PRINT) 505 <br />CERTIFIER TITLE 507 <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED soe <br />CERTIFICATION TIME <br />• <br />Q Yes ❑ No This tank previously hell flammable or combustible materials. <br />indicator prior to work being conducted on the tank. <br />If yes. the lank interior atmosphere shad be Ie-cnected with a combustible gas <br />Certifiers tank management instructions for 30rap dealer, disposal facility, eta <br />A copy of this cartificate shall accompany the tank to the recycling/disposal facility. <br />