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TANK CLOSURE CERTIFICATION FORM <br /> RVsQ — of — <br /> aU51NB55 NAME 3 FACIUTY to 6 t <br /> SITE AooRESS 104 <br /> 9U51NE55 CITY 105 BUSINESS LIP IC6 <br /> TANK OWNER NAME <br /> 300 <br /> TANK CYVFOER ADDRESS <br /> 301 <br /> i <br /> TANK C`rrNER CITY 502 $TATE 50 21P 50A <br /> I <br /> i <br /> fTank s Flammable Vapor Oxygen <br /> (Stats Tank ID*,if applicable) Top Center Bottom Top Center [Bottom <br /> Tank interior <br /> Atmosphere <br /> lReadings <br /> f <br /> III CF=RTIF1rATI10N <br /> , <br /> On examination of the tank, I certify the tank is visually free from product•sludge,scale(thin,flaky residual of tank contents),driseate and Ceoris. I further certify <br /> R that the information provided herein is Ime and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON scs I <br /> CERTIFIER NAME(PRINT) sob Certifier is a representative of the CUPALiA: YES ❑ NO ❑ <br /> CERTIFIER TITLE 507 i <br /> Name of CUPAILIA <br /> ADDRESS <br /> If certifier is other than GUPAfLIA check appropriate box below: <br /> CITY <br /> ❑ Cerdfied industrial Hygienist{CIH) <br /> PHONE <br /> DATE CERTIFIED sae CERTIFICATION TIME ❑ Certified Safety Psofessiona[(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RFHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class ii Registered Environmental Assessor <br /> 0 CSLB Licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑ No This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere shall be re-decked with a combustible gas <br /> indicator prior to work being conducted on the tank_ <br /> Cartifier's tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recydingldisposal facility. <br />