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' TANK CLOSURE CERTIFICATION FORM <br /> 3 %ACILT`/10+ , <br /> 9U51NES51VA/dE. <br /> SITE �00RESS iP+ <br /> ®USIr:ESS GIN ,1 ,OS 3USINE55 ZIP j sCC <br /> S00 <br /> TANK C-wNEA WME \ q + y <br /> TA ER A00R ESS `! <br /> TA HK ER CITY SM STATE '503 caR >� <br /> Tank rt Flammable Vapor Oxygen <br /> (Stale Tank iOs. if applicable) Top Center Bottom Top Canter 3octom <br /> ' Tanx interior <br /> Atmcspnere <br /> I Reaoings <br /> I <br /> III (-PRTECATION <br /> I <br /> I <br /> On examinauen of the tank, I certify the tank is visually free from product,sludge.scale(thin, flaky residual of tank contents),rinseate and de-Ons. I further ceflrfy <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> it <br /> CERTIFIER SIGNATURE <br /> STATUS OR AFFiL1ATICN OF CERTIFYING PERSON sou <br /> CERTIFIER NAME(PRINT) soe Cardfaer is a representative of the CUPAIUA: YES ❑ NO ❑ <br /> CERTIF"rER TITLE: ser <br /> Name of CUPAlLIA <br /> ADDRESS If cerdfier is other than CUPAILIA check appropriate box bekm: <br /> CIT ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> PATE Gi_RTIFIE17 sae CERTiFICA71ON TIME ❑ Certified Salety Professional(CSP) <br /> ❑ Carolled Marine Cfsemmt(CHIC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class it Registered Environmental Assessor <br /> CSLB licensed contractor(with hazardous substance certificate) <br /> ' 1 Yes ❑ No This tank previously hetd flammable or combusisble materials. If yes,the tank interior atmosphere shall be re-checked wdh a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> 1 Czrjriers tank management in5nC1011S far scrap dealer,disposal faality,ate: <br /> I <br /> l <br /> I <br /> I <br /> A copy of this certificate shalt accompany the tank to the recycingldisposal facility. <br />