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TANK CLOSURE CERTIFICATION FORM <br /> BUSINES;NAVE <br /> NIFACIIJTY ID• � <br /> >ITE ap0RE5; �ry•J <br /> euslNE;s aTY <br /> 1 105 dU;iNE;;LP 1 Iq <br /> I TANK CwNFii NAME <br /> ' TA ER Ap0RE55 <br /> TANK p'NNER CITY <br /> 503 STATE W3 ZIP <br /> Tank 3 Flammable Vapor Oxygen <br /> (State Tank 103,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> On examination of the tank,I certify the tank is visually tree 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 STATUS OR AFFILIATION OF CERTIFYING PARSON sas <br /> CERTIFIER NAME(PRINT) sos <br /> CERTIFIER TITLE W7Certifier is a representative of the CUPA/LIA: YES ❑ NO C1 <br /> Name of CUPA/LIA <br /> ADDRESS <br /> CITY If certifier is other than CUPA/LIA check appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED soe CERTIFICATION TIME 11 Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class It Registered Environmental Assessor <br /> 61 CSLB licensed contractor(with hazardous substance certificate) <br /> Y®s ❑ No This tank previously held flammable or combustible materials. II yes,the tank interior atmosphere shall be re-chected with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifiefs tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />