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TANK CLOSURE CERTIFICATION FORM <br /> I FAC-11 11Y 1[);ZNT1F1CA-nQN <br /> 9USINEss NA&AE 3 .AC]uryo. <br /> Heritage Square <br /> WE At3b>ZM ,o+ <br /> 640 N. San Joaquin St. <br /> Rusme3s City ,as aus,NHss IIP :C6 <br /> CA 95205 <br /> N <br /> TANK CVMFR A RE sm <br /> David Warwick <br /> TANK CANER AaaRESS Sol <br /> 5730 Bennett Valley Rd. <br /> TANK dWNEFt CtrY 362 $TAT;,: W3 I ZIP <br /> Santa Rosa CA 95404 <br /> Tanks Flammable Vapor Oxygen <br /> (State Tank ICS.it applicable) Top Center Bottom Top Center i3ottom <br /> Tank Interior <br /> Atmosphere 1500 gal . Bunker Fuel Tan 0 0 0 6 5 0 <br /> Readings <br /> ----T. <br /> III r-E!3jlFjrA11C)N <br /> On examination of the tank.I Certify t visually free from radua,sludge.scale(thin.flaky residual of tank contents).rirlZe2le and debris. I further certify j <br /> that the information provided her t e a ac to to e f rtty knowledge. j <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON IQs 1 <br /> I <br /> L <br /> CERTIFIER NAME(PRIM") Cartifier is a representative of the CUPAILIA.'YES Q NO <br /> C4RTIFFER TITLE 3or I <br /> Name a!CUPadL1A <br /> ADDRESS P.O. BOX 950 If certifier fs other than CUPAILIA c:teck appropriate box below: <br /> CITY S <br /> an Anrjrf-as , CA 95249 P!-SONE ❑ Certified Industrial Hygienist(C1H) <br /> DATE CErRTIFIED son rJ CERTIFICATION TIME C1Certified Safety Professional(CSP) ! <br /> i <br /> ❑ Certified Marine Chemist PAC) ! <br /> 8/12/02 0930 ❑ Registered Environmental Hearth Spedarist(REI-iS) <br /> i <br /> ❑ Professional Engineer(PE) <br /> ❑ C:ass 11 Registered Environmental Assessor 1 <br /> ® CSL3 licensed contractor(with hazardous substance cert fiatte) <br /> ❑Yes ❑No This tank previously held flammable or combust{ble materials. If yes.the tank interior atmosphere shalt be re-CleCked with a combuso0le gas <br /> indicator prior to work being ccnduCed on the tank. N/A <br /> Certifiefs tank management instructions for scrap dealer.disposal fadlity. etc <br /> N/A <br /> I <br /> i. <br /> A copy--it this certificate shall accompany the tank to tt'e reel6n9ldisposal facility. <br />